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8/7/2018
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WOUND CARE IN THE ELDERLY
MICHELLE MOMENEE, APRN, FNP-BC, CWS
DISCLOSURES:
EMPLOYED WITH ELLIOT HEALTH SYSTEMS: CENTER FOR WOUND CARE AND HYPERBARIC MEDICINE
WOUND CARE IN THE ELDERLY
Anatomical and physiological changes in the geriatric population that affect wound
healing.
Socioeconomic factors specific to the geriatric population that affect wound healing.
Wound care interventions and approaches best suited to the geriatric population for
wound healing and prevention.
ANATOMICAL AND PHYSIOLOGICAL CHANGES:
SYSTEMIC AND LOCAL
Age related typical changes
Disease associated alterations
Medication effects
Lifestyle effects
SKIN: LARGEST AND MOST VISIBLE ORGAN
15% total body weight
Function:
Thermoregulation
Primary defense structure
Fluid balance
Communication
HEALTHY SKIN STRUCTURES
http://www.proprofs.com/quiz-school/story.php?title=anatomy-and-physiology-questions-the-integumentary-system
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SKIN AGING
Chronological & Photoaging
Senescence and apoptosis
Oxidative metabolism
DNA mutations
Membrane lipid oxidation
Abnormal signaling
Decreased transport
Protein oxidation
Decreased function
AGE RELATED TYPICAL SKIN STRUCTURAL CHANGES
EPIDERMAL
• Thinning
• Flattening of rete ridges
• Slowed cellular turnover rate
• Decreased inflammatory and immune response
• Decreased nerve ending
• Decreased blood vessels in rete ridges
• Decreased melanocytes
• Decreased Langerhan’s cells
• Decreased Merkel cells
• Keratinocytes resist apoptosis
DERMAL & UNDERLYING
Thinning
Flattening of rete ridges
Decreased blood vessels in rete ridges
Redistribution of fat layer
Decreased blood vessels and thinning of vessel walls
Increased # of MMPS’s, decreased # of inhibitors
Elastin and collagen disorganization
Same # of sebaceous glands, hypertrophic and decreased
oil production
Decreased # and function of sweat glands
SKIN ANATOMY
http://www.fpnotebook.com/mobile/Derm/Anatomy/SknAntmy.htm
AGED SKIN
Decreased flexibility, elasticity and strength
Increased reaction to irritants
Decreased antioxidant protection
Impaired sensation, thermoregulation, vascular
reserve
SYSTEMIC DISEASE
Cardiovascular: decreased cardiac output, atherosclerosis, decreased peripheral flow, edema, vessels thin
Diabetes: PAD, decreased immune response, neuropathy, renal impairment, retinopathy
Cancers: chemo and radiation therapy decreases wound healing
Immune: impaired or overactive response
Endocrine: impaired metabolism, impaired communication
Renal: rapidly aging skin and impaired wound healing
Lymph: edema
EFFECTS OF MEDICATIONS
Inhibits Wound Healing
Antiangiogenic chemotherapy
Morphine
Celecoxib (Celebrex) NSAID, ASA, Ibuprofen, Naproxen
Metformin
Singulair
Valium
Dopamine
Lovastatin, simvastatin
Doxycycline, clarithromycin
Furosemide (Lasix)
Warfarin, Apixaban, Rivaroxaban
Corticosteroids, methotrexate
Nicotine
Promotes Wound Healing
Pentoxifylline (Trental)-for venous ulcers
Cilostazol (Pletal)- for arterial ulcers
Currently being studied:
Topical insulin
Topical oxygen
Complementary approaches
(Levine, 2017)
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LIFESTYLE EFFECTS
SMOKING, ETOH, SWEET TOOTH, STRESS SUN DAMAGE
http://www.instructables.com/id/How-to-make-Homemade-Tanning-Oil/
http://www.top10homeremedies.com/news-facts/10-habits-make-age-faster-look-older.html
SOCIOECONOMIC FACTORS SPECIFIC TO THE GERIATRIC
POPULATION THAT AFFECT WOUND HEALING
FINANCIAL
EMOTIONAL
LIVING ENVIRONMENT
FACTS AND NUMBERS
2010 US Census Report:
40.3 million >65 years
13% of the population > 65 years
Health costs of 65 + age group
3 x more than adult
5 x more than child
LIVING SITUATION
SNF/LTC - 3.1 %
ALF – 25%
Group Home: Independent Living
Single Home alone or with Spouse
Single Home with Family Members
INSURANCE COVERAGE
Medicare A
Medicare B
Medicare D – DME’s, pharmaceuticals
Medicaid
Private Insurance
Private Pay
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POVERTY LEVELS IN THE ELDERLY: 2013
US:
15 %, one in seven
Greater in women than in men
3x higher in Hispanic elders
2.5 x higher in Black elders
NH: 14%
20% of elders in poor health, 1 in 5
HISTORY AND PHYSICAL
THROUGH THE SOCIOECONOMIC LENS
Sensory deficits: blindness, HOH, taste, smell, and neuropathy
Mobility deficits: decreased ROM, balance and gait, bending/reaching
Oral health, dental health, functional ability related to shopping/cooking/eating
Functional ability related to bathing, hygiene, self assessment
Assistance: who is available to provide care
Safety risk: alarm sensors, call for help options
INDIVIDUAL COST OF WOUNDS
Painful
Malodorous
Prevents normal daily routine
Time consuming
Costly
Isolating
Depression
Decline in overall QOL
http://www.thinkstockphotos.com/search/#/M||471559232
WHO HAS MALNUTRITION?
Emaciation
Obesity
http://thechroniclesofb.com/?tag=obesity http://www.torontosun.com/2013/05/13/obesity-obsession-overlooks-underweight-kids
NUTRITION AND HYDRATION
Nutrition
Dietary restrictions-medically prescribed
Amino Acids-arginine, glutamine
Vitamins, minerals
Zinc, copper
Anemia
Malabsorption
Enteral or ONS may be needed
Hydration
Fluid restrictions-medically prescribed
Na restrictions-medically prescribed
Swallowing impairments
Acute illness contributing to fluid loss
Monitor weight, skin turgor, urine, serum Na
Medication side effects
Diuretics
Anticholinergics
NUTRITIONAL STATUS
“Screen and intervene”
Affordability?
Eating alone or with others?
Oral health concerns?
Chronic or acute illness affecting appetite, absorption, intake?
mna-elderly.com/forms/mna_guide_english.pdf
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RECOMMENDATIONS
Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition (ASPEN) “do not recommend using inflammatory biomarkers such as serum protein levels for diagnosis of malnutrition.”
Recommends inter-professional care:
Dx medical reasons for altered nutritional and hydration status
Oral health screening
SLP eval-swallowing ability
OT eval-food prep and feeding ability
Dietitian-eval and monitor nutritional status
(Posthauer, 2015)
SPEAKING OF FOOD…….
ELDER ABUSE
Last reported data from 2005, close to 1,500 cases
Abuse
Neglect
Self neglect
Not always malintended
http://www.nhcadsv.org/elder_abuse.cfm
https://www.dhhs.nh.gov/dcbcs/beas/aboutprotection.htm
SOCIOECONOMIC EFFECTS ON WOUND HEALING
Increasing aging population: increasing aging skin
Large percentage require care giving services
Financial constraints restrict ability to afford care
Nutritional deficits increase wound development and delay healing
Fear and embarrassment: wounds under reported until serious illness
Poor skin hygiene leads to increased risk of wound development
WOUND CARE INTERVENTIONS AND APPROACHES BEST
SUITED TO THE GERIATRIC POPULATION FOR WOUND
HEALING AND PREVENTION
SKIN CARE AS PREVENTION
CLEANSING
Mild surfactant
High in phospholipids
Soft cloth
Decreased frequency
Liquid or foam soaps
pH approx. 5.5
Tepid water
MOISTURIZING
Skin barriers:
Dimethicone
Petroleum
Silicone
Restores skin:
Urea
Glycerin
Hyaluronic acid
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HEALING REQUIRES THE SAME PRINCIPALS
FOR EVERY WOUND TYPE
Ensure blood flow
Manage edema and inflammation
Assess for and treat infection
Manage underlying diseases/conditions
Provide nutritional supports and manage hyperglycemia
Remove unhealthy tissue
Provide moisture balance
Off-load to avoid pressure and trauma
Assist patient with financial and social needs
UNMET NEEDS
http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijd/vol1n2/ulcer1.xml
http://rap.genius.com/Jeezy-real-is-back-2-intro-lyrics#note-2642183
http://www.cmaj.ca/content/165/10/1345/F1.expansion.html
http://www.sunrisemedical.com/Products/jay.aspx?producttype=cushions
http://www.worldwidewounds.com/2008/march/Thomas/Maceration-and-the-role-of-
dressings.html
STAGES OF WOUND HEALING
Hemostasis: platelet aggregation, clot formation, stop
hemorrhage, lay a matrix for cell adhesion
Inflammatory: complement cascade, neutrophil &
macrophage response, acute inflammatory response
Proliferative: 3 days to few weeks, proliferation of
fibroblasts, protein synthesis, angiogenesis, granulation
formation, epithelialization
Remodeling: 7 days to one year or more, increases
tensile strength, although never reaches 100%
Stages Illustrated Stages
http://ethesis.helsinki.fi/julkaisut/laa/kliin/vk/vaalamo/fig3.gif
WOUND TYPES
Skin tears
Diabetic foot ulcers
Venous leg ulcers
Arterial leg ulcers
Pressure ulcers
Surgical wounds
Atypical wounds
Edema related
SKIN TEARS: “WOUNDS CAUSED BY SHEAR, FRICTION, AND/OR BLUNT
FORCE RESULTING IN SEPARATION OF SKIN LAYERS
Prevalence studies (more than 10 yrs old) :
LTC-up to 54%
Home setting-up to 19.5%
Acute setting-up to 22%
LeBlanc & Baranoski (2017)
SKIN TEARS: “WOUNDS CAUSED BY SHEAR, FRICTION, AND/OR BLUNT
FORCE RESULTING IN SEPARATION OF SKIN LAYERS
Contributing Factors
Falls and Minor Traumas
Neuropathy
Cognitive Impairment
Thinning Skin and Xerosis
Adhesive Removal
Handling During Care
Edema
Classifications
Partial Thickness-dermal
Full Thickness-sub dermal
ISTAP: International Skin Tear Advisory Panel
2013 Skin Tear Classification System
Type 1: no skin/flap loss
Type 2: partial skin/flap loss
Type 3: complete flap loss
LeBlanc & Baranoski (2017)
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SKIN TEARS: “WOUNDS CAUSED BY SHEAR, FRICTION, AND/OR BLUNT
FORCE RESULTING IN SEPARATION OF SKIN LAYERS
PREVENTION
Avoid tape/adhesive use
PT/OT referral
Protective equipment
Protective sleeves
Moisturizing skin care
Geropsych-cognitive health referral
INTERVENTION
Irrigate
Approximate and secure
No tape with dressing application
Non-adherent dressing
Protective sleeves
SKIN TEAR DRESSINGS: NON-ADHERENT
GERI-SLEEVES: PROTECTION
http://www.rehabmart.com/resizeimage_send.asp?path=/imagesfromrd/ML-
NONSLEEVE%20Protective%20Sleeves_Skin%20Tears.jpg&width=365&product_name=Protective%20Sleeves
LOWER LIMB ULCERS
Venous:
Accounts for 80% of leg ulcers
Due to venous valvular incompetence or occlusion
Managed with compression
Arterial:
Accounts for up to 20% of leg ulcers, often comorbid venous
Due to impaired arterial circulation
Requires revascularization procedure
Diabetic:
Located on feet, most commonly on plantar surface
High risk for infection
Managed with strict off loading
VENOUS LEG ULCERS
NCBI estimates annual cost of $14.9
billion
Affects 3 million Americans, 1% of the
population
Incidence increases to 8% at age 80
Co-morbid arterial disease in 20% of
the cases
VENOUS STASIS DERMATITIS
http://www.skininfection.com/Resources/ImgLib/Dermatitis.html http://hardinmd.lib.uiowa.edu/dermnet/dermatitisstasis6.html
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VENOUS LEG ULCER INTERVENTION
Debridement
Appropriate topical applications
Infection Rx
Compression for acute Rx:
Contraindications and Risks
CHF
Renal failure-fluid overload
PAD-ischemia
Infection
Pain
Pressure ulcer
MANAGE VENOUS HYPERTENSION AND STASIS
Incompetent valves Interventions
Venous intervention
Compression stockings
Circaid garments
http://www.medicographia.com/2011/12/treatment-of-chronic-venous-disease-pathophysiological-underpinnings/ http://www.spectrumhealthcare.net/products/wraps_bandaging
EDEMA RELATED
LYMPHEDEMA SYSTEMIC DISEASE
https://www.google.com/search?q=cardiovascular+edema&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwi
wqojLvfbSAhXKRyYKHd5YCjkQ_AUIBigB&biw=1600&bih=808#imgrc=WW55e_LBjnZdoM:&spf=192
BARRIERS TO CHRONIC COMPRESSION
Difficult to self apply
Appears “medical”, not fashionable
Costly
Risks: pain, pressure ulcer, infection
Contraindicated in
Infection
Arterial flow compromise
CHF
DVT
Renal disease
HTN
EDEMA EXERCISES
http://slism.com/wpsystem/wp-content/uploads/easy-edema-treatment-01.gif
ARTERIAL ULCER: ISCHEMIA
20 % of leg ulcers
Most commonly located on toes and lateral
ankle/lower leg
Requires procedure to re-establish flow
Typically painful, either “punched out” appearance
or black dry necrosis
Often present with shiny, taut skin. Dark red or
ruddy with dependency, becomes pale with
elevation. Pulses can be absent, difficult to locate,
however are often present. Don’t be fooled by a
pulse.
http://www.ispub.com/ostia/index.php?xmlFile
Path=journals/ijd/vol1n2/ulcer1.xml
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ARTERIAL WORK-UP AND INTERVENTION
• Palpation and Doppler of pulses
• Vascular studies with ABI and waveforms
• CTA with run-off, MRA, Angiography
• Angioplasty
• Interventional cardiology
• Surgical intervention
• Medication
http://www.cardiogallery.com/CVCTA/Aorta%20Iliofemoral%20Run%20Off%20CTA/Aorta%20Iliofemoral
%20Run%20Off%20CTA.html
ARTERIAL FLOW EXERCISES
http://medical-dictionary.thefreedictionary.com/Buerger-Allen+exercises
Buerger-Allen exercises:
1. Elevate feet on padded chair or board
for 1/2 to 3 minutes.
2. Sit in relaxed position while each foot is
flexed and extended then pronated and
supinated for 3 minutes. The feet should
become entirely pink. If the feet are blue
or painful, elevate them and relax as
necessary.
3. Lie quietly for 5 minutes, keeping legs
warm with a blanket.
From Black and Matassarin-Jacobs, 1997.
LEG ULCERS
VENOUS
Compression
Infection
Debridement
Avoid dependent position
Encourage ambulation
Venous surgical intervention
Venous exercises
ARTERIAL
No compression
Encourage dependent position
Infection
Avoid debridement
Re-establish flow
Buerger-Allen exercises
DIABETIC FOOT ULCERS
US annual cost is > $15 billion
11 million Americans diagnosed
with diabetes, 25 % of these will
develop foot ulcers
1 in 15 will undergo amputation in
their lifetime
50% will survive >3 years
DIABETIC OR NEUROPATHIC ULCERS
Diabetic caused by a combination of hyperglycemia, compromised circulation, decreased sensation, and pressure,
neuropathic caused by decreased sensation and ongoing pressure.
Ulcer typically present on plantar surface of foot, heel or toes. Wound often surrounded by thickened callous
tissue.
Infections are common.
Treatment plan often includes and requires serial debridement, total contact casting, and topical wound therapy.
Requires a collaborative approach, involving diabetes management, nursing care, wound care expertise, often
fittings for orthotics, and at times vascular intervention.
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DIABETIC FOOT ULCERS
Interventions
Blood flow
Infection
Glycemic control
Off load pressure
Debridement
Risks
Fall risk
Renal impairment
Hypoglycemia
Bleeding
Pain
Infection
INFORMED BY THE STATS: DM
ADA estimates annual US cost of DM in 2012 as $245 billion
Number of DM diagnosis is rising
1985: 30 million
2000: 177 million
2010: 285 million
Projected in 2030 at 360 million
Stevens, 2015
INFORMED BY THE STATS: DFU
NIH reported in 2015: lifetime risk of DFU for DM is 15 %
Estimated that approx 20% of acute admissions in diabetic population are for the treatment of DFU
Risks associated with DFU include infection, gangrene, amputation, death
Approximated 50-70% of amputations performed are due to DFU
Worldwide: One amputation is performed every 30 seconds for DFU
Stevens, 2015
OFF-LOADING
Temporary off loading shoe
Diabetic shoe insert and shoe
NWB
http://www.veindirectory.org/magazine/article/techniques-
technology/options-for-non-venous-wounds-diabetic-foot-ulcers
DFU CARE
The Facts:
DM pathophysiology leads to high risk for DFU
DFU rates of infection, amputation, mortality and recurrence are dangerously high
Population of DM is increasing
Aging population is increasing
Prevention does decrease DFU rates
Comprehensive treatment plan to
address:
Infection: potent well absorbed
antibioitics, consider ID referral, podiatry/surgical referral, HBOT. Elderly: high risk for Cdiff, nephrotoxicity.
PAD: Consider cardiology and/or vascular referral.
Neuropathy/arthropathy: total contact casting initially, referral to orthotist. Elderly: high risk for falls and injury.
Glycemic control: collaboration with PCP/endocrinology. Elderly: high risk of hypoglycemia.
PRESSURE ULCERS
AHRQ estimates 2.5 million pressure ulcers yearly
US cost: $9-11.6 billion annually
Individual cost $20,900-151,700 per pressure ulcer
CMS reports each ulcer added $43,180 during hospital stay
More US lawsuits for pressure ulcers than falls or emotional distress, and second only to wrongful death suits
60,000 die annually in the US from pressure ulcers
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PRESSURE ULCERS
RISK ASSESSMENT
Braden Scale:
Immobility
Nutrition
Moisture
Activity
Sensory Deficit
Friction and Sheer
INTERVENTION
PT, frequent repositioning, off loading cushions and
mattresses
Feeding assist, Supplements, L-arginine, TPN
Low air loss mattress, frequent incontinence care, barrier
creams
PT, assistive devices, assistance
Protective splinting, frequent repositioning, off loading
PT for transfer and positioning recommendations, lift
sheets, lower HOB less than 30 degrees if tolerated
TREATMENT PLAN FOR PU’S
Off-loading is crucial
Debridement of necrotic tissue
Pulse lavage: CPI
PT/OT modalities-Estim, PSWD, US
Management of underlying disease process
Thoughtful selection of wound care products
NPWT
Nutritional support
Surgical referral
hamill-law.com
PRESSURE ULCER STAGES
DEEP TISSUE INJURY
UNSTAGEABLE HEEL WOUND
http://www.endocrinetoday.com/view.aspx?rid=33061
“TIME WOUNDS ALL HEELS.”
JOHN LENNON
http://reference.medscape.com/features/slideshow/pressure-ulcer-causes
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OFF-LOADING: A COLLABORATION WITH NURSING, ORTHOTIST, AND
PHYSICAL/OCCUPATIONAL THERAPY
Foot ulcers
Waffle boots
Off loading shoe
Custom orthotics
Total contact casting
CROW boot
Crutches
Non-weight bearing status
Wheelchair
Trunk & Other Body Surfaces
Air mattress
Specialty seated cushions
Custom orthotic splints and devices
Floating body part on pillow
HOW TO DETERMINE…WHAT ARE YOU LOOKING AT?
Caused by ischemia due to compression of tissue between a surface and bony prominence
Located over bony prominence, or area of tissue against external source, i.e. tubing
Stage 1-4, un-stageable, or deep tissue injury
Healed by combination of local wound care and pressure reduction
May be partial or full thickness
Caused by inflammation due to contact with moisture, especially when compounded by chemical irritant and/or altered pH
Located where the skin is exposed to moisture: intertriginous folds, perineum, peri anal, peri ostomy and peri wound
Typical moisture sources include urine, fecal matter, wound exudate, and/or perspiration
Partial thickness: epidermal and dermal tissue loss
Pressure Wounds
MASD: Moisture Associated Skin Damage
PREVENTION AND TREATMENT OF MASD/IAD
Structured skin regimen
Gentle cleansing & moisturizing with a product pH that matches skin pH, use a moistened disposable soft cloth versus hospital washcloth
Application of skin protectant or moisture barrier product, typically petroleum for urine and zinc for fecal
Increase frequency of incontinence brief changes
Off-load pressure: reduce risk of pressure ulcer
Avoid friction and shearing
Treat candidiasis, as needed, with antifungal
Treat cutaneous infections promptly
Gray, Mikel (2007)
SURGICAL WOUNDS
Infection
Edema management
Glycemic control
Mechanical forces and tension
http://m3.i.pbase.com/o6/12/421212/1/101374523.kIMZ12if.wrecked_foot_vacuum_dressin.jpg
ATYPICAL WOUNDS
Biopsy unusual wounds or duration > 6 months without improvement
Malignancies
Bullae/pemphigus disorders
Pyoderma gangrenosum
Viral lesions
Vasculitic lesions
Necrobiosis lipoidica diabeticorum
IDENTIFYING ATYPICAL WOUNDS
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PEARLS IN ELDERLY WOUND CARE
Malodor may be treated with Flagyl 250-500 mg topical to wound bed with dressing changes and/or charcoal wound dressing
Pseudomonas is not a common cause of systemic illness, more often colonized, best treated topically with acetic acid, 0.25 to 3% and avoiding moisture
Regional ID update: corynebacterium striatum often culprit in osteomyelitis, have to ask for sensitivities
Medical device is common culprit in pressure injury, pad well
Collaboration is key, as this age group accesses care in multiple settings with multiple disciplines
History taking and plan of care development requires investigative work
Apply viscopaste without Coban to minimize risk, padding can minimize discomfort and pressure risk
Telfa makes a soupy mess
Bactrim is high risk for DM, elderly and renal dx
Off loading can be a dangerous fall risk
Tight glycemic control is high risk for hypoglycemic event, loosen it up a little
Protein, caloric, and L-arginine supplement for wound healing
Zinc supplement with caution
IN SUMMARY:
Chronological and photoaging structural and functional skin changes increase risk of and delay healing of wounds
Systemic illness more commonly found in elders increase risk of and delay healing of wounds
Medications and treatments of illnesses in elders increase risk of and delay healing of wounds
Socioeconomic factors of an increasing aging population who live longer with chronic illness have increasing rates of poverty and decreasing funds for use in the treatment of wounds
Fear of loss of independence is a barrier to seeking care
Safety risks and treatment side effects unique to elders limit treatment options in would healing
Developing plan of care for prevention and treatment of wounds in the elder population will prevent wound care development and minimize wound therapy adverse effects
REFERENCES
Cubanski, J., Casillas, G., Damico, A “Poverty Among Seniors: An Updated Analysis of National and State Level Poverty Rates Under the Official and Supplemental Poverty Measures” Jun 10, 2015. http://kff.org/medicare/issue-brief/poverty-among-seniors-an-updated-analysis-of-national-and-state-level-poverty-rates-under-the-official-and-supplemental-poverty-measures/
Fore, Jane MD, A Review of Skin and the Effects of Aging on Skin Structure and Function, Ostomy Wound Management, vol 52, Issue 9, Sept 2006. http://www.o-wm.com/content/a-review-skin-and-effects-aging-skin-structure-and-function
Gray, Mikel (2007) Incontinence Related Skin Damage: Essential Knowledge. Ostomy Wound Management 2007; 53(12):28-32.
LeBlanc, Kimberly, Baranoski, Sharon, Skin Tears: Finally Recognized, Advances in Skin & Wound Care: The International Journal for Prevention and Healing, Vol 30, No. 2 Feb 2017.
Levine, JM, The Effect of Oral Medication on Wound Healing, Advances in Skin & Wound Care: The International Journal for Prevention and Healing, Vol 30 No 3, March 2017.
MacNeal, Robert J., MD, Effects of Aging on the Skin, http://www.merckmanuals.com/home/skin-disorders/biology-of-the-skin/effects-of-aging-on-the-skin
Park-Lee, Eunice, PhD and Caffrey, Christine, PhD of US Dept of HHS CDC National Center for Health Statistics, Pressure Ulcers Among Nursing Home Residents: United States, 2004, NCHS Data Brief, No. 14, Feb 2009, https://www.cdc.gov/nchs/data/databriefs/db14.pdf
Posthauer, ME, Banks, M, Dorner, B, Schols, J, (2015) The Role of Nutrition for Pressure Ulcer Management: National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance White Paper, Advances in Skin and Wound Care, April 2015.
Stevens, Phil, Med CPO, FAAOP (2015) The Cost of Diabetic Foot Ulcers, The O&P EDGE, Aug 2015, http://www.oandp.com/articles/2015-08_02.asp
West, Loraine A.; Cole, Samantha; Goodkind, Daniel; He, Wan. “65+ in the United States: 2010,” U.S. Census Bureau, P23-212, Government Printing Office, Washington, DC, 2014. https://www.census.gov/content/dam/Census/library/publications/2014/demo/p23-212.pdf
GERIATRIC RESOURCES
Agency for Healthcare Research and Quality http://www.ahrq.gov
Administration on Aging http://www.aoa.gov
National Institute on Aging http://www.nia.nih.gov
Non-Profit Organizations Health and Age Foundation http://www.healthandage.org
American Federation of Aging Research http://www.afar.org
Alliance for Aging Research http://www.agingresearch.org
National Council on Aging http://www.ncoa.org
The National Gerontological Nursing Association http://www.ngna.org
The National Conference of Gerontological Nurse Practitioners http://www.ncgnp.org/
The American Geriatrics Society http://www.americangeriatrics.org/
NICHE: Nurses Improving Care for Healthsystem Elders http://www.nicheprogram.org/
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