Clinical Approach to Chronic Wound Management in Older Adults

Wahila Alam MD; Jonathan Hasson MD, MBA; May Reed MD

Disclosures

J Am Geriatr Soc. 2021;69(8):2327-2334. 

In This Article

Characteristics and Pathophysiology of Types of Wounds

All wounds have the potential to become chronic. Most common chronic wounds can be classified into pressure injury, vascular (venous and arterial), or diabetic ulcers. Chronic wounds share common features; however, understanding the underlying cause is key to successful management.[14]

Pressure Injury

Pressure injury or ulcers develop as a result of pressure or shear forces to skin overlying bony prominences leading to ischemia/reperfusion and tissue injury.[15] Older skin is much more vulnerable to pressure injury due to multiple risk factors, including immobility, nutritional deficiency, urinary or fecal incontinence, and chronic diseases. Current pressure injury classification is based on the clinical appearance of skin and may not necessarily represent the extent of underlying damage, especially in stage 1 or deep tissue pressure injury.[16]

The term pressure ulcer was replaced by pressure injury by National Pressure Injury Advisory Panel (NPIAP previously NPUAP) consensus in 2016. Pressure injury represents all stages including stage 1 and deep tissue pressure injury.[17] The pressure injury classification cannot be used for any other type of wounds (Figure 1B).

Vascular Wounds

Chronic lower extremity ulcerations occur in up to 5% of the population over 65 years of age[18] and are attributed to venous insufficiency, arterial disease, prolonged pressure, neuropathy or a combination.[19–21] It is estimated that the majority of lower extremity vascular wounds are venous in origin followed by arterial disease, with a quarter of the wounds reflecting mixed etiology with both arterial and venous disease as causative factors.[22–24]

These wounds affect an estimated 2.4–4.5 million people in the United States. They last, on average, 1 year, recur in up to 60–70% of patients, and are a significant cause of morbidity due to loss of function and decreased quality of life.

Venous Ulcers

The pathophysiology of venous ulceration is venous reflux that results in increased ambulatory venous pressures leading to superficial chronic inflammation. As this condition, which is associated with aging, progresses, the inflammation and increased hydrostatic pressures lead to the clinical manifestations of chronic venous disease and ulceration.[25] The ulcers are usually shallow and irregularly shaped. Physical findings helpful in determining venous etiology are lower extremity edema, thickening of the skin, discoloration/hemosiderin deposition, large varices, and old healed ulcers[26] (Figure 1C). The most important study to assess venous disease is an ultrasound that includes venous waveform analysis in the superficial and deep systems, color flow analysis, compressibility, waveform analysis, analysis of deep and superficial reflux, and thrombus morphology (if any). Confirmatory studies include catheter-based venography, CT venogram, and/or MR venography examination. The mainstay of treatment of venous wounds is compression (often referred to as UNNA boots), underlying dressings to control/contain drainage, and elevation. For severe venous disease, a vascular surgery referral is helpful. Early treatment of superficial reflux with either radiofrequency or laser endovenous ablation, or ultrasound-guided foam sclerotherapy may speed healing, and decrease recurrence rates.

Arterial Insufficiency Ulcers

Atherosclerosis of arterial vessel walls manifesting as peripheral arterial disease (PAD) can range from asymptomatic disease to critical limb ischemia.[27] PAD is the foremost cause of wound-related mortality and disability-adjusted life years.[28] In contrast to venous ulcers, arterial insufficiency ulcers are particularly difficult to heal due to low tissue oxygen delivery, decreased trans-capillary diffusion, and local acidosis of the wound bed (Figure 1C). Often arterial and venous insufficiency co-exist challenging the diagnosis and management of lower extremity wounds. Most arterial ulcers are full thickness, punched out with smooth edges (Figure 1C). The initial evaluation for suspected arterial compromise includes measures of ankle brachial index, pulse volume recording, and toe perfusion. However, vascular surgery referral and diagnostic arteriography may be necessary if no objective improvement is seen despite a trial of optimal wound care. With substantive tissue loss and intercurrent infection, early revascularization (open or endovascular) can speed wound closure.

Biopsy of the wound (especially in the presence of long-term chronic ulceration) may be indicated to rule out associated scar carcinoma.

Neuropathic Ulcers

Neuropathic ulcers are a serious and potentially fatal complication of diabetes. About 10–15% of diabetic patients develop foot ulcers.[29] The primary pathophysiologic contribution to diabetic wounds is the presence of neuropathy. The lack of sensation leads to foot injuries and deformities, abnormal pressure points, and ultimately to foot ulcers.[30,31] One specific example of diabetic ulcer is the development of both sensory and motor neuropathy, which results in wasting of the dorsal interosseous muscles, leading to splay toe or claw foot deformity. This causes the plantar metatarsal fat pads to be disposed anteriorly, leaving little padding under a metatarsal head. Combined with a sensory defect, this leads to skin erosion and the so-called "malum perforans" ulcer (Figure 1C). Glucose control becomes essential for wound healing in diabetic patients; the goal is to maintain blood glucose at less than 200 mg/dl. Initial treatment is pressure redistribution by offloading the foot with instant or irremovable total contact casting (iCC)[32] and excellent custom footwear. A multidisciplinary approach that includes topical treatments like becaplermin gel was recently reviewed.[31] In some cases, procedures to remove or adjust the metatarsal head may be considered. Limb salvage requires extensive long-term wound care. In severe cases of ulceration, amputation may be the best choice for the patient and should not be regarded as treatment failure.

Atypical wounds

Atypical wounds are a common occurrence in older adults. Atypical wounds or ulcers are those that show unusual clinical features including histology, localization, or resistance to standard therapies. They are generally caused by neoplastic, inflammatory, vasculopathic, hematologic, infectious, or drug-induced etiologies. Examples of atypical wounds are malignant wounds or ones that develop due to vasculitis, gout, autoimmune disorders, calciphylaxis, pyoderma gangrenosum, and trauma as well as bite wounds.[33] Chronic non-healing ulcers that do not respond to appropriate management should raise concern for malignancy and a biopsy should be performed between 4 and 12 weeks after a trial of appropriate treatment.[34]

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