More than skin deep

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(Photo: ivanastar/E+/Getty Images)
(Photo: ivanastar/E+/Getty Images)

In communities where residents routinely explore walking trails and practice yoga, a health threat that often strikes the inactive might be easily overlooked.

But wounds are a real danger for all seniors, whose skin becomes more fragile with the passing years, a range of health conditions and dehydration or poor nutrition.

The susceptible include fully independent or highly mobile residents in assisted living and memory care settings.

“They may not be at risk for pressure ulcers as much, but they're at risk for things like diabetic ulcers or venous ulcers,” says Renee Cordrey, PT, MSPT, MPH, CWS, a former board member of the Association for the Advancement of Wound Care. “If we can address risk factors, then we reduce the odds of wounds happening. And if they do have an ulcer, the quicker we can treat it, the more likely it is to close.”

New options and guidance seeks to help communities provide ongoing skin integrity, even as residents' needs evolve.

A holistic approach that coordinates the efforts of direct and indirect caregivers, nutrition teams, rehab and primary care clinicians is ideal in continuing care retirement communities, according to Michelle Christiansen, vice president of clinical sales and marketing for Medline.

“Taking proactive care of the resident's skin is an extra challenge for elders residing in CCRCs since a lot of residents are independent,” Christiansen says. “Everything from chair padding to diet, to skin care and bathing products, to bedding fabrics can play a role in skin breakdown.”

A staff educated on signs of potential skin damage — even among residents who may try to hide it — and preventive care can be critical to facility-wide success. 

Tracey Yap, associate professor at the Duke University School of Nursing, is a board member of the National Pressure Ulcer Advisory Panel.

She designs and tests interventions for wound prevention and management, with a focus on cueing staff and residents to move regularly.

“Even a medication change that leads someone to sleep more, a fall or a bump could cause a deep tissue injury,” Yap says. “With the emphasis on aging in place ... it's important to have staff really understand the implications.”

A closer look

Added regulatory oversight and a link to reimbursement spur some of the extra attention paid to residents, Cordrey says.

But plenty of opportunities exist to increase vigilance and improve health outcomes in less intense care settings.

“People with a chronic wound try to hide it,” Cordrey says, noting that a pressure ulcer doesn't necessarily draw the same kind of sympathy as other diagnoses. “Sometimes there's a stigma.”

A wound left untreated for too long also could force a resident into a more intense care setting and out of the place they call home, especially in facilities or states that require advanced wound stages to be treated.

Skin breakdown associated with incontinence, or incontinence-associated dermatitis, is the most common form of injury within the broader category of moisture- associated skin damage.

IAD is caused by chronic exposure to urine and/or stool, particularly liquid stool, and manifests as inflammation and sometimes erosion or denudation of the perianal or perigenital skin, explains Julia Melendez, RN, BSN, JD, CWOCN, national clinical director for Joerns Healthcare.

Christiansen says staff should take note of residents who begin wearing dark clothing routinely, refuse to drink liquids or wear fragrances to conceal odor.

Others, she says, might try to double up on disposable absorbent products, so staff should watch for unexpected product loss.

“Caregivers might notice the resident increasingly depends on them for activities of daily life or the resident entirely stops doing things they used to enjoy out of fear of putting pressure on their bladder while moving,” Christiansen says. “Once they stop moving, more problems start.”

Skin care providers constantly are improving products to offer better protection — and ensure better compliance — among people of varying ages and abilities in all corners of healthcare.

Melendez says disposable incontinence garments and products with superabsorbent polymers should be used to absorb urine and stool and wick moisture away from the skin.

“When the patient is in bed, absorptive products should be left open underneath the patient to avoid creating an occlusive environment that increases skin temperature and humidity, which is a significant risk factor for IAD,” Melendez explains. 

For residents with pressure injury in the sacral and/or ischial areas and IAD, Melendez recommends a therapeutic support surface that provides microclimate management to help maintain normal skin temperature, inhibit sweating and reduce excessive skin moisture.

But there's no one-size-fits-all solution.

Though some facilities invest in support mattresses for every resident, Melendez cautions careful observation. It's all about achieving a balance between support and overly dry skin, which can be caused by some high air-loss surfaces.

Likewise for briefs or other garments needed to protect against leaks, says Michele Mongillo, RN, BSN, MSN, RAC-CT, senior clinical director for FirstQuality Healthcare.

Only residents who are completely dependent should wear briefs all day, she says. Otherwise, use the least restrictive product possible. Protective underwear can help residents who are active and toileting on their own but report occasional accidents. Activity-induced leaks — for instance, from a sneeze or deep cough — can be countered with bladder control pads.

“You want to promote as much socialization and dignity as possible,” Mongillo says.

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