The proportion of the world's population aged over 60 years is expected to nearly double from 12% to 22% between 2015 and 2050, and the number of people aged 80 years or older to triple (World Health Organization, 2015).
At a biological level, ageing results from the cumulative impact of molecular and cellular damage over time, leading to a gradual decrease in mental and physical capacity. This decrease is neither linear nor consistent across individuals and is associated only loosely with a person's age in years. The incidence of pressure ulcers, skin tears and leg ulcers increases with age, and these can be difficult to manage in the community.
Dementia is a term used to describe a group of conditions characterised by a gradual impairment in brain function that may affect memory, speech, cognition, personality, behaviour and mobility (Dementia Australia, 2022). As it progresses, functional ability declines, eventually resulting in reliance on carers for many if not all aspects of daily living.
In the whole of the UK, the number of people living with dementia (PLWD) is estimated to be 850 000 and there are around 540 000 carers for this patient group in England (Prince et al, 2014).
How does dementia affect the likelihood of a wound healing?
While older people are generally at a higher risk of sustaining wounds, the Alzheimer's Society (2016) has identified further impediments to wound healing experienced by PLWD. These include:
- Movement and walking: a person may have difficulty changing position without help
- Frailty: this results in loss of protective fat tissue or muscle mass, and the skin can become thinner
- Poor diet and dehydration: not eating and drinking well can lead to weight loss and malnutrition, and increase the risk of skin ulcers (Pivi et al, 2012)
- Incontinence: moisture from leaks can cause skin maceration and damage
- Agitation or restlessness: rubbing of clothes or objects, often over the heels or elbows, damages the skin, increasing the risk of ulceration (Alzheimer's Society, 2016).
- Medication: some medicines may cause skin dryness or drowsiness, leading to reduced movement
- Communication: the person may be less able to express pain or a desire to move.
As a consequence of any or all of these features, PLWD can be vulnerable to developing not only wounds but also subsequently chronic wounds that continue to deteriorate or become hard to heal because of their multifactorial aetiology.
Research on wounds experienced by PLWD
A literature review in 2020 found that PLWD were mostly excluded from research into evidence-based wound care, with most information related to pressure ulcers (PUs) (Parker et al, 2020).
As part of the literature review, a pilot study was conducted to assess the prevalence of wounds in PLWD in long-term care: this was found to be 78%, with a higher proportion of skin tears and pressure injury than among the general long-term care population (Edwards et al, 2017; Parker, 2020). A possible explanation is that a larger number of PLWDs were independently mobile and had different reasons for requiring long-term care.
Pressure ulcers
These can affect any part of the body that is put under continuous pressure, and are most common on bony prominences such as the heels, elbows, hips and base of the spine (sacrum) (NHS website, 2020). Older people are generally at greater risk, particularly if they have difficulty in moving, and dementia makes this risk even higher, especially as it progresses. Carers may sometimes discourage or limit movement because they are afraid of the risk of increasing falls (Close, 2014); however, in doing so, they inadvertently increase the risk of PU development.
PUs are a major concern because they are painful and are associated with large costs for the products and care required to treat them, but they are often preventable (Cullen Gill, 2015). They are also often used as quality indicators in healthcare organisations to monitor, compare and improve the quality of care provided to older people.
A widely accepted classification system for PUs is that devised by the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel, and the Pan Pacific Pressure Injury Alliance (2019) (Table 1). There have been several iterations of this document, which categorises wounds by the depth of tissue involvement, with the last revision published in 2019. Because the depth of some wounds may be difficult to assess due to overlying slough and/or eschar, two further categories have been added since it was introduced.
Table 1. Classification system for pressure ulcers
| Category I | Intact skin with a localised area of non-blanchable erythema |
|---|---|
| Category II | Partial-thickness skin loss with exposed dermis |
| Category III | Full-thickness skin loss |
| Category IV | Full-thickness skin and tissue loss |
| Unstageable PU | Obscured full-thickness skin and tissue loss |
| Suspected deep-tissue PU | Tissue injury hidden under skin |
Early symptoms include parts of the skin becoming discoloured or not blanching (turning white) when pressed. People with pale skin tend to get red patches, while people with darker skin tend to get purple or blue patches.
The treatment and prevention of pressure ulcers depend on their location and severity. The National Institute for Health and Care Excellence (NICE) (2014) has published guidelines on preventing and managing PUs. With a significant focus on prevention, the initial strategies set out in the guidelines centre on carer and patient-focused prevention, which are discussed below.
Moving and regularly changing position
Most people shift around naturally when sitting down, redistributing their weight and relieving pressure points. PLWD, however, particularly those in more advanced stages of cognitive decline, are more likely to stay in one position for a long time (Alzheimer's Society, 2016).
It is important to encourage and remind PLWD to change their position even while sitting. If they can stand, they should be encouraged to do so every couple of hours. Pressure-relieving seat cushions are also available.
Those confined to bed for prolonged periods should have their position changed often to avoid the increased risks of pressure ulcer development and their burden on quality of life.
There is no single recommendation for frequency of repositioning and this should be based on risk assessment and frequent skin examination.
Pressure offloading aids
Pressure-offloading aids are used to redistribute a PLWD's weight away from pressure areas, although there is limited evidence about what types of redistributing devices are best for the relief and prevention of PUs (McInnes et al, 2015).
Feet, including the tips of toes and the heel, are especially prone to pressure injury. The following can be used to address this:
- Bed cradles to alleviate pressure on toes
- Pillows under calves to offload weight from heels
- Foam boots to offload pressure from the heel or lower calf; these may come with removable, shaped sections and can be used in bed or on recliners.
Designated static foam pressure-relieving mattresses or cushions, which often have an in-built pump system to provide a constant flow of air, can reduce the risk of sacral and heel PUs. There is strong evidence that specialist mattresses for PU prevention are better than standard hospital mattresses for avoiding PUs and should be considered as a minimum intervention for high-risk individuals (McInnes et al, 2015).
Nutrition
Adequate nutrition should be ensured by promoting a healthy, balanced diet. Dietary supplementation may improve the nutritional status of PLWD (Pivi et al, 2012).
Additional measures
PUs may develop despite the implementation of the best measures in people near the end of life, and existing ulcers may worsen over time despite excellent self-care and carer practices (Alzheimer's Society, 2016). Given this, a PLWD with an existing PU may also require:
- Dressings designed to best manage and treat the size, depth and exudate produced by the wound
- Surgical or dressing debridement to clean the wound and remove damaged tissue. Optimal wound healing occurs with healthy wound margins and granulation tissue at the wound base (Frykberg and Banks, 2015):
- Surgical debridement is warranted in wounds that are malodorous or wet, suggesting the presence of additional infection which may be at risk of progression or even life-threatening
- Dressings can be used for debridement or maintenance of a wound and can also help prevent infection. They are appropriate in static, slow-to-heal or deteriorating wounds secondary to high exudate, biofilm or infection
- Management for infection: some hard-to-heal wounds can become infected, with cardinal features of infection being worsening erythema, exudate or pain, in addition to systemic clinical signs such as tachycardia and pyrexia. Treatment for an infected ulcer is likely to include antibiotics or special dressings. Ulcers that have been swabbed and cultured, and evidence of infection found, should be treated with tissue culture-guided antimicrobial therapy (Frykberg and Banks, 2015). Empiric treatment based on local antibiotic guidelines can be started while waiting for results to come back.
- Pain relief: pressure ulcers can be extremely painful, so providing regular, adequate analgesia for patient comfort is important. Paracetamol can be an effective, regular analgesic but often requires adjuncts.
Much of the current literature focuses on people with PUs in long-term care or in hospital. More research is required on strategies for home-based care and for patients whose wound care is provided by family caregivers.
Skin tears
Physiological changes that occur as part of the ageing process put elderly people at risk of developing skin tears. These occur primarily on the extremities as a result of friction, or a combination of shearing and friction forces that separates the epidermis from the dermis (resulting in a partial-thickness wound) or both the epidermis and the dermis from the underlying tissue (resulting a full-thickness wound).
The main causes of skin tears are mechanical trauma, often from falls, transfers, wheelchairs or the removal of dressings and adhesive tapes (Battersby, 2009). Skin tears can occur on any part of the body, but are often sustained on the extremities such as the upper and lower limbs or the dorsal aspect of the hands (LeBlanc and Baranoski, 2011).
Results of controlled clinical studies and case series consistently suggest that education and the implementation of prevention protocols reduce the incidence of skin tears in extended care facilities by almost 50% (Ratliff and Fletcher, 2007).
Bank and Nix (2006) reported on the effectiveness of a comprehensive skin tear prevention programme to decrease the incidence of skin tears in a 209-bed urban nursing and rehabilitation centre. Strategies included staff education and the use of skin sleeves, padded side rails, and gentle skin cleansers and lotions. During the course of this 13-month study, the number of new skin tears identified decreased from 8.9% to 4.1% after a series of preventive interventions were implemented (Bank and Nix, 2006).
The International Skin Tear Advisory Panel (ISTAP) convened a group of experts to provide internationally recognised recommendations for the prevention and management of skin tears that were published in 2018 (LeBlanc et al, 2018). They noted that skin tears were frequently under-reported or misdiagnosed, and the financial burden to healthcare systems was not fully known.
Although many classification systems exist, the ISTAP system uses a simple method to classify skin tears, categorising them as type 1, type 2 or type 3 (Table 2).
Table 2. International Skin Tear Advisory Panel skin tear classification
| Type 1 | No skin loss: linear or flap tear where the skin flap can be repositioned to cover the wound bed |
| Type 2 | Partial flap loss: the skin flap cannot be repositioned to cover the whole of the wound bed |
| Type 3 | Total flap loss; total skin flap loss that exposes the entire wound bed |
Skin tears can be reduced or prevented in a PLWD if caregivers are given the education to identify and manage individual and environmental risk factors to enhance patient safety.
Strategies to mitigate against skin tears include:
- Thorough assessment
- Good skin care
- Considerations for fragile skin.
Assessment
All patients at risk of skin tears should have their skin assessed at first visit or admission, and ongoing skin inspection should be incorporated into a daily documented care regimen (Wounds UK, 2015). The skin should be inspected under good lighting and assessed for dryness, bruising, oedema, erythema, pruritus and pain (Ratliff and Fletcher, 2007). Clothing should be inspected for tightness or rubbing.
In non-ambulatory patients, the arms (elbows, forearms and hands) are the commonest sites affected, while the legs are more commonly affected in mobile patients (Hawk, 2018).
Emollients in skin care
Emollients help to restore the barrier function of the skin, reduce itching and increase the level of hydration (Callaghan et al, 2018). A variety of emolliating products such as lotions, creams and ointments are available to treat dry skin.
Before application, it is important to ascertain that the patient does not have any sensitivities or allergies to these products.
Different product ingredients affect use. After bathing, elderly people and their caregivers should be instructed to apply moisturisers or emollients to dry skin areas such as the arms and legs. Emollients should be used for daily skin care, particularly for individuals with fragile or aged skin, and those who have or are at increased risk of developing a wound (Beeckman et al, 2020).
Fragile skin
People with fragile skin should be handled carefully during bathing or position changes (LeBlanc et al, 2018) Pillows can be used to support legs and arms to avoid traumatic injury. Patients should be encouraged to wear long sleeves and long pants for added protection. Rooms should be lit adequately to reduce the risk of bumping into furniture or other objects.
Skin tear treatment
Treatment of skin tears should aim to preserve the skin flap and maintain the surrounding tissue, re-approximate the edges of the wound (without stretching the skin), and reduce the risk of infection and further injury while considering any comorbidities. Basic care practices for an individual with a skin tear are summarised in Table 3.
Table 3. Basic care practices for skin tears
| Control of bleeding | Apply pressure and elevate limb if appropriate |
| Cleanse and debride | Clean and irrigate the wound as per local protocol, removing residual debris or haematoma. If the skin flap is present but necrotic, it may need to be debrided. If viable, the skin flap should be re-approximated to act as a dressing. Most skin tears are not amenable to suturing or tissue adhesives as the skin is usually too thin. Traditional adhesive strips are no longer advised because their adhesive nature increases risk of skin injury. Other topical methods such as skin glue may be considered |
| Manage infection and inflammation | Wound inflammation from trauma should be distinguished from wound infection. Wound infection can result in pain and delayed wound healing; a diagnosis of infection should be based on clinical assessment and infection control measures according to local guidelines |
| Moisture balance and exudate control | Skin tears tend to be dry wounds and adequate moisture balance is essential to promote wound healing and to protect the periwound skin from maceration |
| Monitor wound edge and closure | Skin tears typically heal in 7–21 days, depending on the extent of tissue damage. Practitioners should ensure that all factors that could delay healing (eg diabetes, peripheral oedema or nutritional issues) are addressed |
Most experts recommend non-adherent mesh dressings for ISTAP skin tear types 1, 2 and 3, which help minimise tissue trauma and pain when the dressing is removed (LeBlanc et al, 2016; 2018). An arrow can be drawn to indicate the direction of a skin tear to help minimise trauma on removal. Tubular or roller bandages can be used to secure dressings or to provide additional protection (Stephens-Haynes and Carville, 2011).
Generally, a dressing may be left in place for 5 days unless odour or a strikethrough is noted, or the dressing becomes loose. Transparent and hydrocolloid dressings are generally discouraged because they can cause further skin damage and pain (Ratliff and Fletcher, 2007).
Exudate may also pool under the dressings and cause adjacent skin maceration. Where wounds are very wet, non-adherent gauze may be placed on the skin tear and covered with absorptive gauze and netting or a tubular dressing to hold it in place.
A transparent film does not have a role in wounds with excessive exudate and may give bacteria an ideal environment to multiply (Sood et al, 2014). However, a hole can be cut in a transparent film, allowing any exudate to drain. An adhesive remover may be used and the transparent film should be stretched to break the adhesive seal.
Venous leg ulcers
Venous leg ulcers (VLUs) are a major cause of morbidity and decreased health-related quality of life (White and Ryjewski, 2005). Several factors contribute to the development of leg ulcers, with 80-85% resulting from venous insufficiency (Simon et al, 2004). In the UK, venous leg ulceration and its associated comorbidities cost the NHS approximately £941.1 million a year (Guest et al, 2017).
Venous ulcers (also called varicose or stasis ulcers) are commonly found between the malleoli and lower calf and are typically shallow, with the base covered in granulation and moderate to high levels of fibrinoid material (exudate), and with irregular margins (Grey et al, 2006).
These ulcers arise because of damage to valves in veins resulting from thrombosis or incompetence in varicose veins, which leads to blood pooling in lower limbs. This leads to extravasation of red blood cells and localised inflammation and collagen deposition, which impair healing, eventually resulting in tissue breakdown and ulceration.
These ulcers are a long-term condition with high recurrence rates, risks of infection and prolonged healing times. They are associated with oedema and, in addition to wound care management to address size and exudate, other factors that contribute to venous leg ulcer must be addressed.
Reducing oedema assists with a decrease in exudate and assists with wound healing, and can be achieved by employing the strategies described below.
Leg elevation
Most venous leg ulcers could be healed if patients were admitted to hospital for continuous leg elevation. However, a shortage of hospital beds, the high cost of inpatient care and the need to maintain independence makes this once popular approach rare. Furthermore, ulcers often recur when the patient returns home and resumes their regular lifestyle with their legs in dependency.
Strategies to keep legs elevated while at rest, such as foot stools when seated or the use of recliner chairs, may help prevent the build-up of oedema during the day, which leads to high exudate from venous wounds.
A PLWD may not understand the importance of these strategies and may require regular reminders and encouragement to follow these practices to help with wound management.
Compression therapy
The current standard of care for VLUs involves compression therapy as a means of reducing venous insufficiency of the lower limbs (Couzan et al, 2012). Compression therapy with the application of sustained, graduated compression bandaging or stockings increases venous flow decreases valvular reflux while walking and increases the effectiveness of the calf muscle pump.
The most effective level of compression to overcome venous hypertension has been determined to be 40 mmHg at the ankle (Simon et al, 2004). Patients with mixed arterial and venous ulcers may tolerate only up to 20 mmHg of compression.
Bandage options include short stretch, long stretch and multilayer bandages and stockings.
Unfortunately, compliance with compression therapy can be difficult because of discomfort, pain and poor understanding of its benefit. Achieving compression therapy at desired pressures may cause an initial worsening of pain and exudate, which may be distressing to patients if they are left uneducated on the anticipated benefit.
Intermittent pneumatic compression
In people with limited mobility, intermittent pneumatic compression is a mechanical process that can be used as an adjunct to treat oedematous limbs.
A PLWD may initially have a reduced level of compression to assist with tolerance and hence compliance, followed by gradual increase to the desired level.
Intermittent pneumatic compression can be used in the community to treat patients with significantly impaired mobility or those unable to comply with compression therapy, so it is of particular benefit to PLWD (Comerota, 2011).
Physical movement
Walking should be encouraged in all PLWD. It is an important method of reducing venous stasis and consequent leg oedema by the action of the calf muscles, which enhances venous return.
Conclusion
Although there are guidelines on the evidence-based management of wounds, none address the features of PLWD making wound management in this patient group particularly difficult.
People with dementia in long-term care were found to have a wound prevalence of 78% (Parker et al, 2020), and a higher proportion of skin tears and pressure injury than the general long-term care population.
Routine comprehensive assessment and accurate documentation of wounds in PLWD are necessary to implement some of the strategies discussed in this paper to reduce the risk of new wounds or improve the healing of existing wounds.
KEY POINTS
- Older people are generally at a higher risk of sustaining wounds, and people living with dementia (PLWD) experience additional problems wound healing
- PLWD are more vulnerable than the general population to developing wounds that become hard to heal because of multifaceted physiological changes
- Pressure is a significant aetiological factor that can contribute to wound development and there are a variety of preventative measures that all healthcare professionals can take
- PLWD are prone to getting skin tears and skin tear prevention programmes reduce their risk
- Venous leg ulcers are a major burden on healthcare resources and simple strategies such as elevation and compression can be key to helping them heal
CPD reflective questions
- What factors make people living with dementia particularly vulnerable for developing wounds?
- What recognised systems can you think of to classify pressure ulcers?
- What preventive measures can be taken to prevent pressure ulcers from developing?
- What simple measures can be taken to help venous ulcers to heal?