Looking after the whole patient, not just the hole

Nurses are at the forefront when it comes to wound management in older people, writes Michael Woodward.

The Australian population is ageing. Already 13 per cent of Australians are over age 65 and this is rapidly increasing to 25 per cent – a proportion already achieved in Japan.

A girl born in Australia today has a 50 per cent chance of living to 100 and as health professionals reading this article you have a greater than 50 per cent chance of reaching age 90.
Wounds are more prevalent as we age, and it is imperative that wound clinicians, most of who are nurses, are knowledgeable in manageing wounds in older people.

There are numerous changes of ageing, but disease is also more common as we age and both normal ageing and morbidity can impact on wounds in older people. Important issues to consider include:

• Age-related skin changes
• Polypharmacy, which is much more common in older people
• Poor nutrition
• Poor hydration/access to fluids
• Diseases of ageing
• Syndromes of ageing
• Socioeconomic factors

With older people, it is even more important to assess the whole patient, not just the hole in the patient. This usually requires a multidisciplinary approach with access to a doctor skilled in older patients (such as a geriatrician), other specialists as needed (for example vascular surgeon, dermatologist, plastic surgeon, ID physician) a nurse, podiatrist, dietitian, orthotist, pharmacist and others as needed.

These are not always easily accessed in the community or residential care, and the specialist multidisciplinary wound clinic provides a valuable service for those older patients needing more comprehensive management and assessment.

Fortunately most major cities have such clinics, but there may be long waiting periods to access them and people with limited mobility, or not living in large cities, may find access difficult.

The wound clinician can attend to some of these issues without necessarily requiring the full multidisciplinary approach. The person’s nutritional status can be assessed with a nutritional assessment screen. The BMI (body mass index) is usually an indicator of nutritional status, but should not be relied on alone.

Hydration is best assessed through axillary sweating – if a piece of absorbent paper placed in the axilla remains dry after a minute or two, the person is likely to be dehydrated- this is more useful than postural hypotension/tachycardia, skin turgor or sunken eyes. Pallor can be indicative of anaemia but is best confirmed with a haemoglobin level.

A full list of medications may reveal polypharmacy and in particular if the person is taking agents that may delay wound healing- these include steroids and NSAIDs (which may be over the counter such as Neurofen).

A home visit is the best way to obtain a full list of all the medications the person is using. Peripheral sensation can easily be assessed using a monofilament.

While the astute nurse can carry out much of the initial assessment, the other members of the team may be needed. A doctor is more suitable to assess neurological conditions, including cognitive impairment and other diseases that could impact on wound healing.

The pharmacist is a valuable resource to assess drug interactions and adverse effects, and the podiatrist can provide a detailed assessment of the feet and footwear. Caring for older people with wounds requires the maximal utilisation of the team that is available, and referral lines if some specialties are not at hand.

Socioeconomic factors can particularly affect older people. They may not be able to afford the dressings or even the cost of nursing visits, and they may not have transport to attend health professionals or to go out to purchase wound products or basic food items. They may be isolated and have nobody to assist in applying tight pressure stockings.

Nurses are well equipped in assessing and providing solutions to overcome many of these issues, but again may need other members of the team- such as involvement of the Aged Care Assessment Team. The Australian Wound Management Association is also tackling some of these issues.

Its Elephant in the Room campaign (www.elephantintheroom.com.au), an important part of Wound Awareness Week, is focused on establishing a national subsidised wound product access scheme.

The good news is that age itself is not an illness, and older people with wounds are just as able to heal, and remain healed, as younger people. It usually requires a more comprehensive, team-based approach, but that is both the challenge and reward of successful health care- and the nurse providing wound care is certainly well trained in this interdisciplinary approach.

Indeed, today’s nurse is usually the centre of the team delivering wound care, as has been so for over a century. The main difference over this time has just been the age of the person with the wound.

Associate Professor Michael Woodward is president of the Australian Wound Management Association.

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