Wounds in the Geriatric Population

1. WOUNDS IN THE
GERIATRIC POPULATION
Adriana Salas, MSN, RN, CNS, ANP-BC
Ingrid Kruse, DPM
VA San Diego Healthcare
San Diego, CA
1

2. Outline
WHY WOUNDS ARE IMPORTANT
RISK FACTORS
ASSESSMENT
STANDARD WOUND MANAGEMENT
REASSESSMENT
ADVANCED WOUND CARE
2

3. Wounds are Common
ANY ULCER 12% of the population >65yrs 1
VENOUS STASIS ULCERS 1% of US
population 2
PRESSURE ULCER 0.4 – 38%
70% of pressure ulcers occur in the elderly 3,4,5
3
1. U.S. Census Bureau. Statistical abstract of the United States. 2012. http://www.census.gov/compendia/statab/2012/tables/12s0009.pdf. Accessed 9/15/14.
2. Gillespie DL. Venus ulcer diagnosis, treatment, and prevention of recurrences. J Vasc Surg. 2010: 52:8S-14.
3. Cuddigan J, Berlowitz DR, Ayello EA. Pressure ulcers in America: prevalence, incidence, and implications for the future. Reston VA: National Pressure Ulcer Advisory Panel; 2001.
4. https://www.soa.org/news-and-publications/newsroom/press-releases/society-of-actuaries/default.aspx
5. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington,DC: National
Pressure Advisory Panel; 2009.

4. Wounds are Expensive
Foot infections are the most common reason for
hospitalization in Diabetics
PRESSURE ULCER COST
$43,180 - $151,500 per hospital stay
$9.2 -$15.6 billion total U.S. cost 1,5
LEGAL COST
2nd leading cause for litigation in long term care4
Medicare and Medicaid services stopped reimbursing acute
care facilities for treatment of pressure ulcers in 2008
4
Diabetes Care 1998;21:2161-2177 and JAPMA 98:166,2008

5. Morbidity
Physical decline
Delayed rehabilitation
Infection
Amputation
Depression
Financial burden
Death
5
NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer
Prevention Points. NPUAP.org

6. Risk Factors
Modifiable
Tobacco
Incontinence
Malnutrition
Diabetes
Hypertension
Vascular Disease
6
Non-Modifiable
Skin
Muscle
Fat
Mobility
Cognition

7. Assessment of Wounds
Location
Stage/Size
Base Tissue
Exudate
Perimeter
Pain
Infection
Odor
7

8. Venous Stasis Ulcers
TREATMENT
Compression & Elevation
Perforator Ligation
Phlebectomy
Stripping
Sclerotherapy
Laser Therapy
8
1. Falanga, V., Fujitani, R. M., Diaz, C., et al (1999), Systemic treatment of venous leg ulcers with high doses of pentoxifylline: efficacy in a randomized, placebo-controlled trial. Wound
Repair and Regeneration, 7: 208–213. doi: 10.1046/j.1524-475X.1999.00208.x
2. Image: http://3.bp.blogspot.com/-ye1j4BSJ5VA/Ud9-93LC0qI/AAAAAAAABx8/IBDXEDmjhHA/s1600/Chronic+Ulcers+2.jpg

9. Neuropathic/Diabetic Ulcer
TREATMENT
Pressure Relief
Proper shoes
9

10. Arterial Ulcers
STUDIES:
Ankle Brachial Index (ABI)
Toe-Brachial Index (TBI)
Segmental Pressures
Waveform Analysis
TCPO2, Angiogram 1
10
1. D Holtman, V Gahtan. Peripheral Arterial Perfusion: is it adequate for wound healing? Wounds. 2008: 20(8): 230-235.
2. Image: http://www.angiologist.com/wp-content/uploads/2010/08/Rutherford_6.jpg
TREATMENT:
Balloon angioplasty, stent, or bypass surgery1

11. Pressure Ulcers
TREATMENT:
Pressure relief
Temperature control
Moisture control
11
1. Image: http://1.bp.blogspot.com/--f1gXWksxF0/TxUdgP8iwtI/AAAAAAAAA-I/O_4nc6O_CIU/s1600/IMG_0418.JPG

12. Common Sites For Pressure Ulcers
12
http://img.docstoccdn.com/thumb/orig/41604968.png

13. Stage I Pressure Ulcer:
Non-blanchable Erythema
13
NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer
Prevention Points. NPUAP.org

14. Stage II Pressure Ulcer:
Loss of Epidermis and Dermis
14
NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer
Prevention Points. NPUAP.org

15. Stage III Pressure Ulcer:
Subcutaneous Fat Layer
15
NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer
Prevention Points. NPUAP.org

16. STAGE IV PRESSURE ULCER:
Exposed Bone, Tendon Or
Muscle
16
NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer
Prevention Points. NPUAP.org

17. Unstageable:
Full Thickness, Depth Unknown
17
NPUAP Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/Pressure Ulcer
Prevention Points. NPUAP.org

18. Deep Tissue Injury:
Intact Skin Or Blister
18
1. Pressure Ulcer Stages/Categories. NPUAP.org http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stNPUAP agescategories/Pressure Ulcer
Prevention Points. NPUAP.org
2. http://woundeducators.com/wp-content/uploads/2014/01/suspected-deep-tissue-injury.jpg

19. Mechanical Debridement
19
http://www.curezone.org/upload/_N_Forums/Natural_Heali/Wound_Packed.jpg

20. Enzymatic Debridement
20http://in.hartmann.info/534.php

21. Sharp Debridement
21
1.http://www.podiatry.com/images/desertfootsite/images/Debridement-1.jpg

22. Wound Maceration
TREATMENT
Paint wound edges
with betadine, avoid
occlusive dressings.
22
https://wocn.confex.com/wocn/2007AM/techprogram/images/2414-0.jpg

23. Hypertrophic Granulation Tissue
• TREATMENT: non occlusive
dressing, steroid cream low
potency x 5-7 days, topical
antibiotic, compression with
foam dressings, Silver nitrate
sticks.
23
1. Sephen-Haynes, J., Hampton S. Achieing effective outcomes in patients with over granulation: wound care alliance UK. www.wcauk.org/downloads/booklet_overgranulation.pdf
retr9eved 9/23/14
2. Image:https://woundcare-today.com/news/special-report/wound-care-today-special-report-overgranulation

24. Peri-wound Yeast Infection
Treatment: topical or oral antifungal
24
1. image: http://www.oley.org/lifeline/TubetalkMA07.html 2. http://www.monarchlabs.com/mdtdressings

25. Wound Infection
• SIGNS/SYMPTOMS:
induration, redness, warmth,
purulent discharge, increased
pain, fever, leukocytosis,
elevated CRP
• STUDIES: MRI, bone
biopsy, bone culture
• TREATMENT: topical, oral
or intravenous antibiotics
25
http://healthh.com/wp-content/uploads/2014/06/diabetic-foot-ulcer-
pictures-3.jpg

26. Wound Odor
TREATMENT:
• Dressing with activated charcoal
• Metronidazole 0.75% gel
• Frequent dressing changes
• Dakins Solution
26
Image: http://s.hswstatic.com/gif/smelly-feet-1200x800.jpg

27. Reassessment
MEASUREMENTS:
– Pressure Ulcer Scale for Healing (PUSH) tool 1
– Bates-Jensen Wound Assessment Tool (BWAT) 2
PICTURES: Obtain consent per facility
protocol
FREQUENCY: Daily until a working dressing
change is established, then at least weekly
27
www.npuap.org Pressure Ulcer Scale for Healing (PUSH) PUSH Tool 3.0
http://www.geronet.med.ucla.edu/centers/borun/modules/Pressure_ulcer_prevention/puBWAT.pdf

28. Sheehan et al. Diabetes Care 2003;26:1879-1882.
28

29. Wound Healing Prediction
• New Wounds that do not become 50 %
smaller in 4 weeks will likely fail to heal
and turn into a Chronic Wound!
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30. The Chronic Wound
• “Non-healing Wound”
• “Stalled Wound”
• “Problem Wound”
30

31. The Chronic Wound
1.Infection – Biofilm, Osteomyelitis
2.Hypoxia – Edema, Vascular disease, Nicotine
3.Poorly controlled Diabetes, Malnutrition
4.Trauma – Too much Pressure!!
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32. Chronic Wound
 All risk factors addressed and corrected
 But wound still not healing :
Consider using Advanced Wound Care
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33. Advanced Wound Care
Technologies
1. Negative Pressure Wound Therapy
2. Growth Factors: Regranex
3. Bioengineered Skin Substitutes:
Apligraf, Dermagraft, Grafix
4. Extracellular Matrix :Oasis, Integra
33

34. Negative-Pressure Wound
Therapy
(Wound Vac)
Introduced in the US in 1997
produced faster wound-healing and
faster granulation tissue formation than
standard wound care
Armstrong et al:Lancet366:1704,2205
34

35. Negative Pressure Wound
Therapy , KCI
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38. Growth Factors: Regranex
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40. Bioengineered Skin Substitutes
Products with living cells as functional skin
equivalents
Recruitment of stem cells
Production of growth factors
Stimulation of angiogenesis
Re-epithelialization: Substrate for keratinocyte migration
Modification of inflammatory processes: Recruitment of neutrophils,
prevention of biofilms
Mansbridge J. J Biomater Sci Polymer Edn 2008;19:955-968.40

41. Apligraf®
Organogenesis
 Living bi-layered dermal-epidermal skin substitute
 Dermal layer: fibroblasts in bovine type I collagen
 Epidermal layer: keratinocytes
 Cells from human neonatal foreskin tissue
 FDA-approved for venous leg ulcers, diabetic ulcers
 Shipped overnight, viable for 2-3 days
41

42. Dermagraft®
Shire
 Bioengineered Dermal substitute
 Fibroblasts seeded on a bio-absorbable mesh
 Cells derived from human neonatal foreskin
tissue
 FDA-approved for diabetic ulcers
 Preserved at -70°C with 6-month shelf-life
42

43. Dermagraft® Apligraf®
Bioengineered Skin Substitutes
43

44. Grafix
Osiris
• Cryopreserved Placental Membrane
• Contains extracellular matrix rich in
collagen, growth factors, stem cells,
epithelial cells
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45. Dermagraft
• Leg ulcer for over 1 year's duration
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46. Dermagraft
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49. Surgical Debridement
• In case of an abscess, incision and drainage
is ESSENTIAL with debridement of all
abscessed tissue.
Consensus Development Conference on Diabetic Foot
Care, 1999,Boston,MASS
Diabetes Care, 1999:22:1354-60 49

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61. Summary
1.Diagnose and correct reversible risk factors
2.Manage wound bed
3.Assess healing after 4 weeks of standard
wound care
4.If healing<50% consider Advanced Wound
Therapies
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62. Questions????
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