Abstract: The prevalence of wounds, particularly pressure ulcers, has been collected over several years with little sustained improvements in overall rates. Consideration and appreciation of the complexity of the heterogeneous nature of the elderly population in the United States as well as the wounds themselves may offer some insight as to why prevalence rates seem so intractable. Frailty, as a descriptive term, has not achieved consensus among health professionals but nevertheless denotes a permanent loss in functional ability. It is common to find care of the frail elderly partitioned into treatments of discrete symptoms. This can often mean treatment goals are established without consideration of the burdensome impact of the treatments themselves for the frail elderly. These interventions, often fruitless, do not prioritize quality-of-life issues, limit independence, and result in further isolation of the frail elderly. Prevalence evaluations are a valuable tool in understanding and measuring the magnitude of wounds in both community and healthcare institutions. However, clinicians must further segregate and appreciate the complexity and diversity of wounds as a sequel of multiple influences among the frail elderly. Healthcare interventions should recognize and accommodate the dynamic nature of the functional decline of the frail elderly. Wound healing, to the exclusion of quality-of-life goals for the individual frail elderly, may not be the gold standard. Comfort, dignity, and control may be better measures of success.

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valuation of wound prevalence among the frail elderly must consider the likelihood that the data does not adequately focus healthcare resources toward patient-centered management strategies. Prevalence, as well as incidence, has been used to establish index values against which healthcare providers measure the success of their global strategies to reduce the occurrence of skin breakdown. Despite significant advancements in wound-related science, prevalence rates continue to exceed most clinicians’ goal levels. A shift in the paradigm of wound healing to extend the definition of success to include not only complete closure but also containment and prevention of degradation will allow patients their fullest possible degree of control and functionality.

Review of the Literature

       Published in 1995, a meta-analysis by Smith¹ reviewed nursing home patients over the age of 65 and found prevalence rates ranging from 17% to 35%. The analysis specifically excluded ulcers related to peripheral vascular disease and/or neuropathy. Published literature review ranged between 1980 and 1994. Through a prospective study of pressure ulcer prevalence conducted between 1992 and 1995, Baumgarten et al.² found that 10.3% of over 2,000 nursing home admissions presented to the nursing home with 1 or more stage II or greater pressure ulcers. More recently, an analysis of Minimum Data Set (MDS) data of hospital-based skilled nursing facilities³ found a prevalence of 18.4% at admission for 68 hospital-based skilled nursing units in Missouri in 1999.
       A basic recognition of the myriad of influences contributing to skin breakdown is reflected in the MDS Resident Assessment Instrument (RAI) system that triggers, upon the finding of pressure ulcer risk, assessment of 8 discrete factors: fecal incontinence, immobility, bedfast status, peripheral vascular status, pressure ulcer history, use of restraints, and neuropathy.⁴ Beyond these physical considerations, the heterogeneous concept of frailty complicates the clinician’s ability to effectively provide patient-centered support to the elderly that may not include wound healing as a primary objective of care. Kaufman⁵ described how healthcare providers view frailty as a medical problem that must be deconstructed into discrete identifiable components, which are then treated. This “medicalization” of the frail elderly causes clinicians to treat symptoms rather than patients (Figure 1). Chronic wounds among the functionally declining elderly must be viewed using a different prism than healing and prevention alone.

Figure 1

       The ACOVE project, Assessing Care Of Vulnerable Elders,⁶ was designed to establish a comprehensive set of quality-assessment tools for the frail elderly. Recognizing the heterogeneous nature of the frail adult, ACOVE concluded that 32% of Medicare beneficiaries were “vulnerable elders” based on the Medicare Beneficiary Survey to determine functional status. The Medicare survey evaluated the functional disability and limitations of the seniors and found these factors to be more significant predictors of death and further functional decline than specific clinical conditions. The concept of frailty as a series of episodic, progressive, and irreversible losses⁷ allows clinicians to frame the occurrence of skin breakdown in a more dynamic model that adjusts interventions and strategies of care accordingly.
       An analysis of nursing home residents diagnosed with advanced dementia helps illustrate the impact and value to patients when there is earlier recognition of irretrievably declining health status. Mitchell et al.⁸ reviewed MDS data from June 1, 1994 to December 31, 1997 to identify persons over the age of 65 with advanced dementia who died within 1 year of admission in New York State nursing homes. This evaluation is instructive, as dementia is a frequent comorbidity of the frail elderly and indeed plays a pivotal role in most designations of frailty. The study’s goal was to contrast the dying experience of residents with advanced dementia to a benchmark of palliative care provided to cancer residents with a life expectancy of less than 6 months.
       Study findings are presented in Table 1.

Table 1

The 1,609 residents with dementia included in the analysis received more aggressive interventions, including feeding tubes, invasive laboratory tests, and restraint use just before death as compared to the group of 883 cancer residents. Despite interventions, over half of both groups died within the first 6 months of evaluation. As anticipated for the cancer cohort, 92% died by the sixth month. Within the dementia group, however, few residents were designated as terminal, yet 71% died by the sixth month of evaluation. Only 20 (1.1%) of the total residents with advanced dementia were designated as likely to die within 6 months of nursing home admission. This lack of recognition, or more likely acknowledgement, of the terminal status of many frail advanced dementia residents results in care interventions that likely restrict independence, influence level of cognition, and can be painful or repugnant to the recipient of the treatment.
       The potential restorative impact of burdensome interventions, such as feeding tubes, frequent dressing changes, and intravenous therapy, must be weighed against the limitations and burdens they place on residents. For example, in this analysis, 25% of the dementia group died with feeding tubes, while only 5.2% of the cancer group had feeding tubes at the time of death.
       The Mitchell study concluded that nursing home residents with advanced dementia are not recognized as having a terminal condition and do not receive care that promotes palliation. Treatment choices that prioritize palliation rather than cure simply reorient healthcare providers to consider the whole patient rather than just specific symptoms.

Discussion

       Skin breakdown, especially among the frail elderly, is a particularly complex medical event. Both prevention and treatment warrant not only the objective evaluation of physical factors but also consideration of those issues related to the quality of life for the individual elderly frail adult. Only then can a determination be made about realistic preventability of breakdown. In the case of existing breakdown, priority of wound healing is ranked from the patient’s perspective.
       Nursing homes care for about 5% of the elderly in the US, and 56% of that population is incontinent of urine,⁹ while an estimated 30% are fecally incontinent.¹⁰ As judged by the aforementioned RAI triggers, incontinence is intimately linked with the risk of skin breakdown. As a functional deficit, both forms of incontinence effectively isolate the affected elderly adult from full participation in the world outside his or her home or institution. Indeed, incontinence is likely to have triggered placement in a nursing home. The irreversible functional losses, including intractable incontinence, reflect the multiple medical morbidities, immobility, and cognitive impairments that must be accommodated when designing wound care interventions for the frail. The problem is expected to increase in parallel with the growth in the US elderly population. The Department of Health and Human Services (DHHS) estimates that persons over 65 have a 40% chance of entering a nursing home. In addition, DHHS estimated that in 2005, 9 million Americans would need long-term care.¹¹
       Evaluation of wounds with treatment focused on selection of the ideal topical dressing or protective devices alone will not provide a satisfactory conclusion to care from either the caregiver’s or patient’s perspective. Wound healing may not be the priority goal for chronic wound sufferers. Instead, focus on control of symptoms, such as odor and pain, may accomplish tangible and valuable outcomes. Relief from either or both of these symptoms can dramatically reduce the isolation many patients suffer as a consequence of chronic wounds. The thoughtful integration of palliation into care choices does not relegate treatment to an acceptance of failure. Rather, it anticipates and incorporates the priorities of health from the patient’s perspective.
       Future research that evaluates the frail elderly will necessarily be limited by the multitude of variables that must be accounted for during data analysis. Multiple illnesses at varying levels of severity, polypharmacy, cognitive status, and general compliance to medical management recommendations will all confound the ability to generalize results from disparate studies.

Conclusion

       Prevalence numbers alone blunt the complexity and diversity of influences that lead to the occurrence and recalcitrancy of skin breakdown among the frail elderly. Although measuring prevalence, as well as incidence, can inform clinicians of the universe of skin breakdown, it is incumbent upon today’s practitioners to further parse the data. Segregation of the frail elderly from the general prevalence number is the first step toward designing strategic care that recognizes and accommodates the dynamic nature of the functional decline of the frail elderly.