UBC Objectives: Care of the Elderly

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Assess and manage skin breakdown and wounds in the frail elderly

Skin breakdown is common in the frail elderly, often who are consistently putting pressure on a given skin area due to immobility and impaired skin integrity and ability to heal secondary to age and comorbidities. Once a "pressure ulcer" has been identified, it is important to perform an assessment, document findings, and devise an appropriate management plan. It is important to understand the patient's general medical history to identify reversible conditions and precipitating or aggravating factors, as well as to identify what supports are currently in place to assist the patient with wound management and activities of daily living. Physical examination and documentation are also important. UpToDate provides a simple diagram that summarizes a pressure wound staging score (National Pressure Ulcer Advisory Panel), and this is useful in terms of providing followup care to assess progress (or lack thereof) of healing, and to communicate wound severity with other health care providers. 

It is also useful to document physical measurements of wound (location, length, width, depth, discharge, etc.) and capturing photos can also help.

Wound care follows some basic principles, and may include different strategies depending on individual patient circumstances. The UpToDate article, "Clinical staging and management of pressure-induced skin and soft tissue injury" (2018), from which the above staging diagram was also pulled, suggests the following as a general approach to caring for pressure wounds:

• Reduce or eliminate underlying contributing factors by providing pressure redistribution with proper positioning and support surfaces.
• Provide appropriate local wound care, which may include debridement for patients with necrotic tissue, based on the ulcer's characteristics (this may include treating for secondary infection). Depending on community resources, consider home wound care nursing support.
  • According to the staging scale (above), this UpToDate article recommends the following approach depending on wound staging:
    • Stage 1 skin injuries can be covered with transparent film for protection. The development of a stage 1 pressure injury should be taken as an indication that the patient is at high risk for more serious ulcer development, and intensive preventive measures should be taken. 
    • Stage 2 pressure injuries require a dressing that maintains a moist wound environment. These wounds generally require little debridement.
    • Stage 3 and 4 pressure injuries generally require debridement of necrotic tissue and coverage with appropriate dressings and possibly treatment of infection.
• Provide analgesia as indicated. Consider adjunctive therapies, such as negative pressure wound therapy. 
• Optimize patient nutrition and chronic disease management.
• Monitor and document the patient's progress.
• Provide appropriate psychosocial support.