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

Wound Treatment

Removal of dead or devitalized tissue with debridement is the first step in promoting the healing of chronic wounds. This can be accomplished using various debridement methods like autolytic, enzymatic, mechanical, surgical, low-frequency ultrasound, or sterile maggots.[42] The exact choice should incorporate patient preference and whether their goal is healing or preventing the wound from getting worse. The decision to debride lower extremity ischemic wounds should be made with extreme caution and a vascular assessment should be performed before debridement. Dry, ischemic lower extremity wounds are best treated conservatively.[43] Debridement prepares the wound bed for the next step, which is the formation of granulation tissue to provide the foundation for new skin formation.

Chronic wounds carry a high antimicrobial burden. Controlling bacterial overgrowth and managing infection is another key to promote wound healing. Wound cleansing can be achieved with normal saline or other commercial wound cleaners. To reduce bacterial bioburden, dressings impregnated with honey (medihoney), iodine, silver, methylene blue, or polyhydroxybutyrate (PHB) can be used. Metronidazole gel is used to decrease the presence of anaerobes, especially in ischemic or fungating wounds.[44,45]

Moisture balance is important during wound healing in order for cells like fibroblasts to proliferate, migrate, and synthesize collagen. A lack of moisture will result in a dry wound that hinders cellular migration. Using a gel-based dressing or foam dressing may be more appropriate in this situation. Alternatively, excessive drainage will result in wound maceration with damage to surrounding skin, leading to failure of epithelialization. Use of absorptive dressings like alginates and foams, and in appropriate settings using negative pressure wound therapy (NPWT) avoids maceration. Use of skin protectant before dressing application is a key step in protecting the adjacent skin, especially in frail patients.[46]

Difficult to heal wounds may require advanced dressings if that is within the patient's goals of care. Human-derived skin substitutes suspended in animal or synthetic extracellular matrix and other bioengineered dressings are considered in some cases. However, these dressings require special training and cost may limit their use. (See Table 2 for some commonly used dressings based on wound characteristics.)

In addition to wound treatment, specific attention to the cause of the chronic wound is an integral part of the management strategy and mitigates the risk of recurrence. Pressure injury requires pressure reduction surfaces and techniques, like low air loss or air fluidized mattresses and repositioning. Compression therapy is the mainstay of venous ulcers. Arterial ulcers may need referral to vascular surgery for consideration of revascularization. Diabetic foot ulcers require pressure reduction with iCC.

Despite aggressive wound management, some wounds remain difficult to close, especially atypical wounds like malignancies, rheumatologic wounds, or calciphylaxis. For others, the goal of treatment becomes palliative management, which is a common strategy in debilitated older adults who seek a comfort-focused approach. See Table 2 for some commonly used dressings that can be utilized for the management of chronic wounds or for use in palliative situations. In the latter, where the goal is to keep the older adult comfortable, dressings that require less frequent changes and, at the same time, control the amount of moisture in the wound bed are preferred. Examples include absorbent foam and other soft dressings that can remain in place for up to a week.

Hyperbaric oxygen therapy (HBOT) has many physiologic effects that could promote tissue repair, and reports of its efficacy in wound healing date back to the 1950s.[47] HBOT has multiple approved indications and is used for the treatment of carbon monoxide poisoning, decompression sickness, and gas embolism. Consequently, HBOT is now available in many urban settings, which has led to its use for a variety of poorly healing wounds for which the data are still controversial. Expert consensus is that the use of HBOT in chronic wounds is best supported in diabetic foot ulcers, but its long-term efficacy even in this setting remains to be established.[48]

Experimental therapies for chronic wounds and interventions that are not widely available (such as 3D bioprinting, gene/growth factor/stem cell-based interventions, electrostatic, plasma, ultrasound, and laser treatments), are evolving and have been recently reviewed by others.[49–51] Broad use of many of these novel methods will be limited by availability, cost, and the necessary expertise for effective utilization.

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