The Potential Role of Zinc Supplementation on Pressure Injury Healing in Older Adults

A Review of the Literature

Melissa Heintschel, MS, RD, LD; Roschelle Heuberger, PhD, RD

Disclosures

Wounds. 2017;29(2):56-61. 

In This Article

Abstract and Introduction

Abstract

Introduction. Compromised nutritional status is common among older adults (aged ≥ 65 years) and is a risk factor for pressure injuries (PIs), which may lead to poor clinical outcomes. The aim of this review was to determine whether or not poor PI healing in older adults is a result of suboptimal zinc status.

Methods. A literature search was performed in PubMed from 2001 to 2016 using the key words: "zinc status," "pressure ulcer," "pressure ulcers in older adults," "wound healing," and "zinc sulfate." Inclusion criteria consisted of adequate sample size, nonacute setting, clinical trial or observational study, sound methodology, and generalizable findings for primary and secondary outcomes, which included food intake, oral nutritional supplement (ONS) consumption, risk for malnutrition, nutrient loss from wound exudate, and lab values.

Results. Of 41 total studies, 10 satisfied the inclusion criteria and investigated PI in older adults versus nutritional intake. Both standard and specialty ONS interventions, which contain additional fortification, improve outcomes, though findings are inconsistent regarding formulations preferable for the treatment of older adults. Monitoring for nutritional deficiencies, including Zn, is essential for optimal patient outcomes.

Discussion. Recently, Zn in combination with ONS containing additional kilocalories, protein, and other trace elements, has been investigated for PIs. Although both standard and specialty ONS interventions improve outcomes, findings are inconsistent regarding preferable formulations for the treatment of older adults. Monitoring for nutritional deficiencies, including Zn, is essential for optimal patient outcomes. Unreliability of biomarkers for frank Zn deficiency make diagnosis uncommon, and oral Zn sulfate administration has not shown significant effects on PI outcomes in the past.

Conclusion. This population benefits from the clinical application of supplementation with preparations containing Zn, added calories, protein, and other trace elements. This improves outcomes, decreases healing time, and mitigates comorbidities.

Introduction

The development of pressure injuries (PIs) is a significant problem in health care settings. Pressure injury prevalence varies from 8.52% to 32.2% in long-term care (LTC) and 2.9% to 19.1% in home-care patients, and stage 1 and 2 PIs make up the majority of skin lesions.[1,2] Approximately 2.5 million patients are treated annually for PIs in US health care facilities, and an estimated $11 billion is spent annually on PI treatment.[3,4] There are 88.3% US LTC residents aged ≥ 65 years, and 45.2% aged ≥ 85 years.[5] This population is prone to compromised skin integrity.[2] Additionally, they are susceptible to nutrition-related risk factors including a decreased appetite and altered thirst; dysphagia, self-feeding deficits, or other eating problems; and unintentional weight loss.[6] These risk factors contribute to malnutrition and nutritional deficiencies, which include zinc (Zn) deficits. A cross-sectional study[7] found that Zn deficiency in older adults was associated with risk for malnutrition. Consequently, nutritional deficiencies and malnutrition associated with aging further increase the chances of developing a skin injury or delayed wound healing.[6,8]

Pressure injuries are defined as "localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device."[2] There are 3 stages of wound development and healing. The first, the inflammatory phase, increases fluid and cell influx to the wound location to provide needed oxygen and nutrients to enhance regenerative processes, and, consequently, results in decreased immunity and increased susceptibility to infections.[8,9] The second, the proliferative phase, also is considered the building phase;[8] this phase consists of the synthesis of collagen, reticulin, and elastin from fibroblasts for new tissue growth.[8] The final stage is the remodeling phase, where cellular activity and the number of blood vessels in the area return to normalcy.[8,10] In order to support the immune response during the first 2 phases, nutritional needs increase from 25 kcal/kg to 30 kcal/kg energy and 0.8 g/kg to 1.0 g/kg protein daily to 25 kcal/kg to 35 kcal/kg and 1.2 g/kg to 1.5 g/kg for PIs.[8]

Repositioning programs for pressure relief, selection of mattresses, and wound care are important considerations in PI treatment.[11] Currently, there are more than 3000 non-nutritional products on the market for adjuvant therapeutic use.[11] Nutritional interventions can include oral vitamins/minerals, therapeutic diets, and oral nutritional supplementation (ONS). Considering the connections between nutritional deficiencies, risk of malnutrition, and PI development, close nutrition monitoring along with appropriate interventions should be considered to improve wound healing outcomes.

Zinc plays a vital role in protein metabolism, regulation of gene expression, immunity, and the inflammatory response, all of which play an important role in wound healing. A deficit of Zn may delay processes in all phases of wound healing.[12] The purpose of this review is to determine whether there is a body of evidence to support the hypothesis of poor PI healing (as measured by both surrogate measures and biomarkers) in older adults is a result of suboptimal Zn status.

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