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Aging Skin: More than just Gray Hair and Wrinkles

Integumentary Issues in the Geriatric Population

Heather McCormack PT, DScPT, CWS

Objectives

– Describe morphologic skin changes in the geriatric population

– Explain age-related issues that affect wound healing and exercise prescription in the elderly

– Distinguish wound dressings/therapy interventions to be used with caution in the geriatric population

– Describe specific clinical assessments of circulatory and sensory systems

– Recall prevention strategies related to wound development

Skin Facts • Largest organ of the body:

Average person has 2 square meters of skin. 15% of the total body weight. 19 million cells per square inch of skin 7% of the skin cells are melanocytes 300 sweat glands per square inch of skin

• Entire skin is replaced every 28 days. 9 pounds of dead skin cells are shed in one year 50% of the dust in your home are dead skin cells

Skin Facts • Body hairs grow for 2-6 years

20-100 hairs are shed each day Pigmented and unpigmented hairs exist

• Human skin is home to more than a 1000 species of bacteria

• Lipids keep skin moist and healthy • Skin color is determined by the activity of

melanin cells 6 months for babies to develop permanent skin tone Pheomelanin colors skin yellow to red Eumelanin colors skin dark brown to black 1:110,000 people have no pigmentation (Albinism)

• Sweat does not smell, bacteria that feeds off sweat does

• There are around 14 different fungi species between the toes

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Skin Function

• Protection

• Temperature control

• Vitamin D metabolism

• Excretion

• Reception of external stimuli

• Immune Defense

• Personal identity

• Allows motion Sussman and Bates-Jensen

Aging: By the Numbers

Generation Born Age Now

Matures 1920-1940 76-96

Boomers 1940-1960 56-76

Generation X 1960-1980 36-56

Millenials 1980-2000 16-36

Young Old

Thicker

Tension

Elastic

Smooth

Thinning Lax

Fragile

Wrinkles

Morphology of Aging Skin

• Reductions

– Cell numbers

– Fiber numbers

– Structure numbers

– Structural thickness

• Result

– Functional decline of skin

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Types of Factors in Skin Aging

• Intrinsic – Genetically driven

– Time based

– Irreversible

• Extrinsic – Environmental

– Lifestyle • Medications that alter normal cellular response

• Smoking

Extrinsic Factors of Skin Aging • UV and Ionizing

Radiation (80% of the damage)

– Damages nucleic acids and proteins

– Increases reactive oxygen species and free radicals

• Smoking – Reduced oxygenation – Reduced proliferation of

fibroblasts, macrophages – Reduced wound edge

contraction

• Environmental Pollutants

• Mechanical and Chemical insults

Smoker Non-smoker

Intrinsic Factors in Aging Factor Result

10-50% thinning of epidermis

Fragility and susceptibility to injury from blunt force trauma

10-40% reduction in melanocytes per decade

Uneven pigmentation, susceptibility to UV damage and DNA alteration Graying hair

Decreased Langerhans cells

Decreased immune response , decrease ability to kill cancer cells, increased risk of infections

Flattening of the dermal papillae and epidermal rete ridges

Increase risk of skin tears and layer separation with minimal trauma

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Intrinsic Factors in Aging Factor Result

Decreased size (and type) of Collagen and Elastin

Reduced strength and resiliency, skin sagging

Increased number of senescent cells – alive but not responding

Decreased cellular response and delayed wound healing

Reduction in cytokines and chemokines and their receptors

Reduced cellular response for the inflammatory phase of wound healing

Decreased Hyaluronic Acid, fibroblasts, GAGs, and mast cell in the ECM

Thinning and disorganization of the dermis , increased dryness and wrinkles in the skin

Intrinsic Factors in Aging

Factor Result

Decrease sweating Decreased body temperature control, changes skin pH

Decrease sebum production ~60% Decreased barrier function, change in pH to alkaline , increased pruritus and eczema, xerosis

Intrinsic Factors in Aging

Factor Result

30% reduction of nerve receptors and decreased neurotransmitters

Altered pain, heat, cold, pressure awareness

Decreased vascularity – smaller vessels, decreased angiogenesis

Decreased oxygen and nutrient delivery, delayed or impaired wound healing capacity

Thinning subcutaneous fat layer

Loss of protection to underlying structures

Decreased estrogen levels Decreased skin health and repair ability, prolonged inflammatory phase

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Skin Failure

• Multifactorial process that is related to the other organ systems function or dysfunction

• Skin deterioration is frequently the outward manifestation of faltering physiology

• Just like the other organ systems, skin failure can be acute, chronic, or end-stage.

Normal Wound Healing

• Requires

– Vascularization

– Granulation

– Collagen Deposition

– Reepithelialization

Risk Factors: Wound Healing & Aging

• Smoking

• Sun Exposure

• Medication Considerations – Polypharmacy

• Concomitant Conditions – Incontinence

– Poor Eyesight/poor lighting

– Malnutrition

– Balance impairments

– Depression

– Impaired cognition

They have a wound…Now what ??

1. Determine the cause

– Pressure

– Vascular compromise

– Neuropathy

– Trauma

– Disease

2. What should the plan of care include:

– Dressings

– Off-loading

– Exercise

– Protection

– Edema control

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Skin Assessment

• Color

• Temperature

• Texture

• Hydration

– Pinch test

• Presence of Hair

• Nails

Pressure Point Assessment

• Bony prominences must be assessed for discoloration, boggy or firm tissue, increased temperature, skin disruption, maroon or deep purple discoloration.

• Assess all furniture and off-loading devices – including bathroom equipment

Circulatory Assessment • Pulses • Ankle Brachial Index (ABI) • Skin Discoloration

– Hemosiderin staining

• Skin Temperature • Rubor of Dependency • Venous Hypertension

– Varicosity – Telangiectasias

• Venous Filling Time test

Rubor of Dependency

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Ankle Brachial Index VALUE CLINICAL COORELATION

> 1.3 Non-compressible vessel disease

0.7-0.9 Moderate symptoms with exercise

0.5 Symptoms at rest

0.3 Associated with gangrene/necrosis

Ankle Brachial Index

ANKLE BRACHIAL VALUES

Normal 1.0-1.3

Low Normal 0.9-1.0

PVD/LEAD <0.9

Borderline

Perfusion

<0.6-0.8

Severe Ischemia <0.5

Critical Ischemia <0.4

Bonham P, Flemister B. Guidelines for management of wounds in patients with

lower extremity arterial disease. Clinical Practice Guidelines, (Series No. 1).

Glenview, IL: Wound Ostomy Continence Nurses Society; 2002.

At what ABI value is it safe to apply compression?

1. 0.8

2. 0.6

3. 0.4

Venous Filling Time Test

1. Position patient supine

2. Observe superficial veins on the dorsal surface of the foot

3. Elevate the limb 60°

4. Hold for 1 minute or until veins empty

5. Place the extremity in dependent position

6. Record time for veins to refill

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Venous Filling Time Results

Normal 5-15 seconds to refill

Venous

Insufficiency

<5 seconds

Arterial

Insufficiency

>20 seconds

Venous Hypertension

Varicosity

Telangiectasias

Sensory Assessment

• Monofilament Testing

LEAP Program. http://www.hrsa.gov/leap/

Trauma or Disease

• Fall history

• Signs of abuse or neglect

• Health history for systemic disease

• Always check for melanoma with ABCDs

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Wound Dressings: Oxygen and Water Vapor Transmission

Permeable

Semipermeable

Occlusive

• Loose-weave Gauze

• Fine-weave Gauze

• Calcium Alginate

• Impregnated Gauze

• Semi-permeable Film

• Semi-permeable Foam

• Hydrogel

• Hydrocolloid

Wound Dressings: Ability to Absorb

Most Absorbent

Least/Non-Absorbent

• Calcium Alginate

• Semi-permeable Foam

• Loose-weave Gauze

• Fine-weave Gauze

• Hydrocolloid

• Hydrogel

• Impregnated Gauze

• Semi-permeable Film

Problematic Wound Dressings

• Heavy Adhesives

– Semi-permeable films

– Hydrocolloids

– Tapes

Problematic Wound Dressings/Edema Control

• Tight securing dressings

– Roll gauze and ace wraps

– Vascular compression or pressure/shear problems

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Off-loading

• Temporary footwear • Off-loading orthotics • Sacral cut-out and other

types of seating cushion • Body positioners for

supine and semi-side lying

• Specialty beds, wheelchair cushions, custom shoes

• Gait training, transfer training, safety assessment !!!

Exercise

• Wide variability in physical fitness at the same chronological age.

• Extra care with therapy band to avoid skin tears.

• Check blood pressure and, if needed, glucose prior to exercise.

• Ovoid over-heating due to decrease in sweat glands.

Prevention

Prevention

Prevention

Prevention

Prevention & Wellness Strategies

• Assessment overall health including nutrition

• Foot screening !

• Skin Protection

• Edema Control

• Clothing and Shoe Assessment

• Mobility Assessment

• Environment Assessment

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Skin Protection

• Sunscreen and protective clothing

• Protective sleeves for arms and legs

• Avoiding architectural barriers/trauma

• Correct skin products

• Incontinence

A sunscreen with SPF 40 is twice as effective as a sunscreen with SPF 20.

1. True

2. False

Sun Screens & Protective Clothing Avoiding Trauma

• Skin Tears – Typical Sites

• Arms – Non-ambulatory seniors

– Due to additional handling by assistants

• Legs – Ambulatory population

– Blunt trauma by equipment

– Transfer Education

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Skin Tears

Associated with • Senile Purpura--40% • Advanced Age • Sensory Loss • Compromised Nutrition • Previous Skin Tears • Cognitive Impairment • Dependency

65%

Protective Sleeves

• Non-compressive sleeves

• Protection from trauma

Xerosis in Aged Skin

• Humidification

• Room temperature as low as comfortable

• Warm not hot bath/shower

• Use of correct skin products

• Reduce bathing frequency to 1-2 times per week

• Check hydration status

Correct Skin Products

Soaps Lotions

Remove the sebum and

lipids

Emollients

Moisturizers

Trap water

Daily bathing with non-

emollient soap discouraged

Humectants

Draw moisture

Non-rinse body washes less

drying

Lotions and Creams

Classified by amount of

solids to liquids they

contain

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Incontinence • Urine and feces are acidic

– Incontinence Associated Dermatitis

• Mobility and balance issues

• Diuretics and urgency

• Dependence in ADLs

Edema Control

• Elevation

• Compression

– Wraps

• Ace wraps

• Low compression wraps

• Multi-layered wraps

– Stockings

Clothing and Shoe Assessment

• Foot Assessment

– Calluses, corns

– Abnormal wear patterns

– Extra width &/or depth shoes

• Clothing Assessment

– Tight, poor-fitting, or unwashed clothing

Mobility and Environmental Assessment

• Mobility – Balance, Gait, Transfers, Gait Aids, ADLs

• Lighting – > 65 years

– 70% more lighting for visual acuity

• Home Barriers – Clutter

– Floor coverings

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Skin Aging Objectives

– Describe morphologic skin changes in the geriatric population

– Explain age-related issues that affect wound healing and exercise prescription in the elderly

– Distinguish wound dressings/therapy interventions to be used with caution in the geriatric population

– Describe specific clinical assessments of circulatory and sensory systems

– Recall prevention strategies related to wound development

Questions?

References

Doughty DB, McNichol LL. Wound Ostomy and Continence Nurses Society Core Curriculum Wound Management. Wolters Kluwer 2016. Farage MA, Miller KW, Elsner P, Maibach HI: Characteristics of the aging skin. Adv Wound Care 2013; 2(1) : 5-10. Goodman CC, Fuller KS. Pathology: Implications for the Physical Therapist 4th ed. St. Lewis: Elsevier, 2015. Hettrick H: The New ABnCs of Skin Care: Aging, Bariatric, Non‐Caucasian Skin Considerations for the Healthcare Provider. Presentation March 2015 to Buffalo Catholic Health Wound Conference. http://www.chsbuffalo.org/files/pdf/Aging%20Non-Caucasian%20and%20Bariatric%20Skin-%20Hettrick.pdf Accessed 1-3-2016. Hughes MC, Wlliams GM, Baker P, Green AC: Sunscreen and Prevention of Skin Aging – A Randomized Trial. Annals of Internal Medicine 2013; 158(11): 781-790. Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A clinical source book for healthcare professionals 4th Ed. HMP Communications, 2007. LeBlanc K, Branoski S: Skin tears:state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Wound Care 2011; 24(9): 2-14. Myers BA. Wound Management: Principles and Practice 3rd ed. Upper Saddle River New Jersey, Pearson, 2012. Papakonstantinou E, Roth M, Kara G: Hyaluronic acid: A key molecule in skin aging. Demato-Endocrinology, 4:3, 253-258 Poljsak B, Dahmane R: Free Radicals and Extrinsic Skin Aging. Dermatology Research and Practice 2012 article 135206 Quan T, Fisher GJ: Role of age-associated alternatives of the dermal extracellular matrix microenvironment in human skin aging: a mini-review. Gerontology 2015; 427-434. Vierkotter A, Krutmann J: Environmental influences on skin aging and ethnic-specific manifestations. Dermato-Endocrinology 2012: 4(3): 227-231. Zouboulis CC, Makrantonaki E: Clinical aspects and molecular diagnostics of skin aging. Clinics in Dermatology 2011: 29: 3-14.