Chronic Wounds: Palliative Management for the Frail Population—Part IV

Patient-centered factors. Cognitive impairments: Depression, anxiety, and delirium. A frail elderly patient with a chronic nonhealing wound is likely to present with an extensive medical history that includes a wide range of medications, disturbances in sleep and activity patterns, episodes of medical set backs, and disease exacerbation. For these patients, it is common to find evidence of depression, anxiety, and some form of delirium. Additionally, it is important for clinicians to avoid making conclusions about the cause of delirium without adequate work up. It may be appropriate to consult an infectious disease specialist to help eliminate infection as the root cause for changes in mental status. These symptoms inhibit the frail patient from engaging fully in their interactions with family and loved ones. Detection and treatment of these symptoms can immeasurably improve the lives of frail patients and facilitate continued personal growth with loved ones. Table 2 is intended to facilitate the recognition of these symptoms in the frail elderly and identify treatment options. Pain. It is generally unknown how much, if any, pain is experienced by the frail elderly patient with an open chronic wound. However, it is likely that this population of patients probably experiences some degree of pain. Although very little is available in the literature that details the experience of pain perceived by elderly patients with chronic wounds, it remains a high priority for symptomatic management. Assessment of the elderly patient is complicated by diminished capacities in both cognition and communication. Table 3 outlines a conceptual model for defining and segregating the types of pain most likely experienced in the presence of a chronic wound.88 The model distinguishes three different pain components associated with chronic wounds. The first, noncyclic acute wound pain, describes a single episode of acute wound pain. The second category, chronic wound pain, refers to persistent pain that occurs without exogenous stimulation. This category of pain is difficult to manage because its origin may be indiscernible as its etiology is often multifactorial. For example, dry, scaling skin, which is quite common among the elderly, is often accompanied by unrelenting pruritus, which may be aggravated by a sensitivity to topical agents being used. The third, cyclic acute wound pain, is associated with manipulation of the wound, usually through treatments or position changes. Palliative management of the frail elderly with chronic nonhealing wounds can reduce or eliminate the cyclic acute pain associated with wound manipulation and positioning. An important consideration in pain control or perhaps even pain avoidance is the assessment and anticipation of the need for anesthetics for dressing changes, debridement, and movement. Shifting the priority of care to providing comfort and relief from suffering over the demands of an aggressive wound management protocol can change the quality of a patient’s life. Pain control is possible in most cases, regardless of how longstanding the pain is. However, qualitative description of the type and degree of pain among frail elderly patients may be difficult to elicit because of communication deficits or even low expectations for pain relief. Consequently, the assessment for pain must be comprehensive, including not only what the patient is able to articulate and what is observed during physical examination but what is known about the pain associated with specific chronic wound types. Accurate assessment of pain, even among cognitively impaired patients, has been facilitated by visual analog scale (VAS) and the faces pain rating scale (FRS), which are not dependent upon a patient’s ability to verbally describe the nuances of each type of pain they experience.89 The management of pain is an important palliative goal. The experience of pain is disruptive to patients, families, and caregivers. Pain prevents patients from realizing specific quality-of-life goals. To achieve palliative management of pain, treatment must weigh the value of pain relief against the availability and preferences of the patient regarding routes of administration for analgesic agents. Table 4 reviews some considerations for the commonly used routes of drug administration. Pain management will always require coordination between selected topical treatments, the timing and frequency of those treatments, and pain-relieving medications. For example, anesthetic options for managing pain associated with dressing changes may include use of incremental strengths of topical lidocaine ointment. Additionally, physical and occupational therapy techniques offer options for relief from other complications, such as muscle spasms and contractures associated with the bed-bound patient. Nutrition and hydration status. Despite a plethora of recommendations, protocols, guidelines, and consensus reports, very little research is available to guide and support any specific treatment strategy for frail elderly patients. Most clinical research that forms the foundation for current nutritional recommendations was performed on animals, burn patients, and surgical patients. Nutritional support traditionally calculates formulas based on consideration of protein serum levels, hydration, assessment of possible alterations in gut absorption capacity, volume tolerance, and potential competing systemic factors. Adapting recommendations and devising plans that effectively control all these factors in the frail elderly cannot always be successful. Frail patients with chronic wounds usually present with longstanding histories that include incrementally diminished nutritional statuses associated with poor dentition, side effects of medications, social isolation, and chronic infections. Placement of gastrostomy tubes and intravenous lines may be complicated because of risks associated with aspiration, infection, and noncompliance with patients having diminished mental capacity. Additionally, supplemental enteral feedings rely on a functional gut capable of absorbing the needed nutrients. Diminished albumin levels, associated with protein wasting, result in osmotic imbalances, which cause intravascular volume depletion. When fluids are increased under these conditions, peripheral edema often results, making the elderly more uncomfortable and less likely to cooperate with attempts to improve overall fluid status. But for those frail elderly that have elected not to prioritize wound healing, nutritional formulation can more freely consider the social implications and potential isolation that aggressive nutritional supplements may invoke. Nutritional deficiencies that lower serum albumin to less than 2g/dL are associated with prolonged inflammatory phase and delayed wound healing from decreased fibroplasias, neovascularization, cell synthesis, and wound remodeling.90 Among older adults in long-term care, the prevalence of protein-calorie malnutrition ranges from 50 to 85 percent. Aging is not a primary cause of malnutrition; however, older persons are at higher risks for not meeting dietary recommendations. The elderly may suffer sensory changes that diminish their senses of smell and taste, reducing the pleasure and, therefore, the interest in eating. Other factors that may place the elderly at risk for malnutrition include vision impairment, tooth loss, chewing or swallowing difficulties, side effects of medication, digestion, mood disorders, functional impairments that limit access to food, or illness that prevents adequate intake.91 Patients who present with multiple and longstanding illnesses that have either been unresponsive or minimally responsive to disease management techniques should be considered for nutritional care plans that emphasize symptomatic relief and quality of life rather than nutritional repletion. Control and prevention of diarrhea, establishing and maintaining an osmotic equilibrium, and providing food that is appealing to the patient may be more important to the frail elderly than pursuing aggressive repletion efforts. The communication techniques described earlier can be utilized to establish realistic expectations regarding the patient’s likely response to nutritional supplements. Alternative options that focus on quality and symptom goals rather than on establishing a nutritional status that is supportive of wound healingcan be discussed. Palliative principles can be readily applied to nutritional care plans for the frail patient with wounds having only symptomatic management objectives. The goal of a palliative nutritional plan is to achieve balance between providing nutritional supplements selected to optimize biochemical status and considerating the food preferences and eating styles of each individual patient. Appetite stimulants, including steroids (e.g., prednisone) and alcohol, while improving intake and providing a positive social impact, result in adding only fat mass, not lean mass. But for the palliative patient, the social value of being able to break bread with family and loved ones may meet care goals despite the neutral or even negative effects on overall nutritional status. Incontinence. Urinary incontinence is a complex phenomenon that is frequently considered an inevitable consequence to aging. Aging alone does not cause incontinence; however, there are types of incontinence with reported higher incidence rates among the frail elderly.92 Residents of long-term care institutions have a reported prevalence rate for urinary incontinence of approximately 50 percent. Identified risk factors among this population include dementia, mobility impairment, male gender, and behavioral problems.92 Effective management of incontinence among the frail elderly with chronic nonhealing wounds is often a prerequisite to controlling the immediate wound environment, including bacterial burden, odor, and sometimes even pain. Table 5 outlines age-related types of incontinence, their causes, and elements of evaluation. In most long-term care facilities, assessment and definition of the causes for incontinence are supported by the minimum data set (MDS) assessment instrument. This instrument, structured to evaluate patients at scheduled intervals, has a dedicated section for continence status that triggers a problem solving approach through the resident assessment plan (RAP) process. Additionally, the Agency for Health Care Research and Quality (formerly the Agency for Health Care Policy and Research) published guidelines for urinary incontinence in adults in 1992, with a revision in 1996. Urinary incontinence is a critically important factor in the management of chronic wounds. Symptomatic management of urinary incontinence can address wound stabilization, odor, and quality-of-life goals. Among the institutionalized frail elderly with chronic wounds, especially wounds located in the trunk region, attempts to control incontinence can be quite frustrating for providers and family alike. Bladder training exercises presume a moderate amount of cooperation from the patient, which may be unrealistic in the presence of delirium, dementia, or diminished levels of alertness. The use of an internal device, such as a Foley catheter, is not an option for incontinence control. The associated risk for urinary tract infections renders this a nonviable method for simple control. Frequent toileting can theoretically control the impact of incontinence on wounds and surrounding skin, but even the most rigorous toileting schedule cannot prevent all incontinence incidents. Although there have been multiple attempts by the durable medical supply industry to once and for all resolve this issue, the problem remains a vexing one. The prevalence of fecal incontinence increases with age and is often observed along with urinary incontinence. Fecal incontinence among the institutionalized elderly is reported to be nearly 30 percent.93 For aging women, changes in the sphincter mechanism are associated with injury during childbirth, which eventually leads to fecal incontinence and postmenopausal hormonal changes. A lifetime of prolonged and excessive straining during defecation can also contribute to eventual fecal incontinence.94 In most cases, fecal incontinence is due to local factors, such as undetected fecal impaction, rather then deterioration of mental functioning. However, in a study performed in 13 French institutions, including eight nursing homes, new cases of nontransient (lasting >2 days) fecal incontinence had worse cognitive functions at baseline than those who did not develop fecal incontinence.93 The French study examined over 1,000 residents of which 234 developed fecal incontinence over a 10-month observation period. Of the population studied, 16 percent (37 of 234) died during the study, compared to 6.7 percent (64 of 952) of the continent population. This study identified fecal incontinence as a marker for poor health. Other causes for fecal incontinence for which the frail elderly population is particularly at risk include CVA, dementia, depression, diabetes, and rectal prolapse.94 Any deterioration of a patient’s mobility or limitations in the physical environment that affects toilet access can negatively influence the frail elderly patient’s ability to maintain fecal continence. Fecal incontinence viewed from a palliative perspective demands resolution to achieve odor control, increase social participation and activity levels, and prevent wound bed contamination. Treatment for fecal incontinence will depend on the results of a thorough assessment that reveals the contributing factors for the incontinence. When it has been determined that limitations to the environment, including toilet access, clothing, and privacy, are factors, treatment will focus on removing these barriers. Alternatively, when the underlying cause for incontinence cannot be ameliorated, as occurs with neuropathy associated with a brittle diabetic patient, then treatment will focus on restoring dignity through containment devices, skin protection, and odor control.94 If a vulnerable wound bed cannot be adequately protected from regular exposure to fecal incontinence, consideration should be given to more aggressive management approaches, such as a temporary diverting colostomy. Activity and mobility impairments. Restrictions or limitations to activity and mobility levels can have far reaching impacts on quality of life as well as precipitate other complications. Immobility is the key factor that distinguishes the frail elderly with chronic nonhealing wounds. The frail elderly patient’s ability to successfully heal chronic wounds is inextricably linked to the degree of their immobility. Certainly, reduced mobility has been linked to the incidence of some of the chronic wounds that this paper seeks to explore. Both fecal and urinary incontinence also have been associated with changes in mobility when it affects ease of toileting. Activity restrictions may diminish the social value and, therefore, interest in meals, which may contribute to malnutrition. The loss of muscle tone associated with mobility restrictions may contribute to the severity of venous ulcers and lower-extremity edema. Immobility increases a patient’s dependence on others to accomplish virtually all activities of daily living. There is very limited opportunity for institutional staff to provide the kind of one-on-one attention required to identify and support individualized activity care plans. Treatments related to activity must have the latitude to consider, from the patient’s perspective, the value of a turning schedule. Turning may be harmful or even scary to some patients, while offering immeasurable relief to others. Turning may be contraindicated because it may cause cyclic pain, while passive range of motion exercises for that same patient may reduce joint pain and provide comfort. Family members who actively participate in the care of a frail elderly patient may be an invaluable resource to achieve a higher level of activity and mobility than could otherwise be provided. Gaps in Treatment Options for Nonhealing Wounds Chronic nonhealing wounds represent a class of medical complication that has frustrated caregivers, enraged family members, formed the basis of medical negligence lawsuits, and, all too often, precipitated social isolation and diminishment of self worth among the patients who suffer from them. Some of the areas of chronic wound management that must be considered and adapted to a palliative model for nonhealing wounds are discussed here. Whole patient assessment. Evaluation of a chronic wound alone will not provide the necessary elements required to informatively chose palliative nonhealing treatment objectives over aggressive healing or closure goals. Establishment of nonhealing objectives for a frail elderly patient with a chronic wound is not borne out of resignation; rather, it is the result of a comprehensive assessment of the whole patient. Assessment includes review of each individual’s overall health status and personal goals. Clinicians must weigh difference factors, such as presence of complicating chronic diseases (e.g., diabetes), presence of Kwashiorkor, Marasmus, or other severe types of protein-calorie malnutrition, feasibility of meeting energy requirements for healing with nutritional supplements, and determination of the best approach to ensure the highest quality of life attainable. Research. Probably the most challenging aspect of researching the frail elderly are the limitations inherent in focusing on a frail elderly population who have limited lifespan, are usually polymedicated, and are usually suffering from a variety of diagnosed and undiagnosed diseases. Never the less, research efforts must systematically identify the characteristics of frail elderly unlikely to successfully heal a wound without sacrificing a more valued level of functional status or dignity. Key elements that need development include the following: • Comprehensive wound assessment (as described previously) • Determination of the influence of preexisting diseases or conditions and their associated medications • Assessment of type, degree, and frequency of pain associated with wounds • Profile of nutritional status and a realistic assessment of the feasibility for achieving additional objectives designed for wound closure • Assessment of the patient’s personal objectives for comfort, dignity, and independence weighed against the demands of wound healing treatments. Research designs should collect outcomes data on large groups of long-term care patients and retrospectively analyze the data in an attempt to identify healing profiles. Once a healing time frame for chronic wounds has been firmly established, then attention to early deviation from the expected course can be addressed.95 Patient weight, body temperature, and initial wound stage have recently been identified as potential factors predictive of healing.96 Some have reported a tripling in mortality when a pressure ulcer fails to heal.97 The association between the presence of a pressure ulcer that fails to heal and death has been the subject of multiple studies over the past 20 years. Certainly the inference that if pressure ulcers were prevented then mortality could be reduced, at least in part, is responsible for the current regulatory and litigation environment that ascribes negligence to the incidence of pressure ulcers. The establishment of a validated tool or process by which all clinicians can reliably determine the value of nonhealing endpoints for individual patients is an important goal for healthcare. It is a logical extension of palliative principles. Standards that are universally applied can facilitate third-party reviews that readily distinguish between patients with actively applied nonhealing treatments and those for whom nonhealing wounds were the consequence of inadequate or inappropriate care. This tool will establish for third-party payers, government regulators, and malpractice attorneys two very important facts. First, the care and treatment of the frail elderly is not necessarily characterized by neglect or withdrawal of services when a chronic nonhealing wound is present. Second, treatments can legitimately focus on the delivery of symptomatic relief and patient dignity over wound healing goals. Other aspects of chronic wounds also need further analysis, such as the frequently associated presence of xerosis with chronic wounds. We must improve our understanding to determine whether dry skin does, in fact, have a causal relationship with skin breakdown. Until we can distinguish between many of the commonly held beliefs associated with chronic ulcers and facts borne out of well-structured research, little progress can be made toward establishing a palliative arm to wound care treatments. Establishment of nonhealing endpoints in product and treatment testing. The June 2000 Food and Drug Administration (FDA) Guidance for Industry for Chronic Cutaneous Ulcer and Burn Wounds indicates, “Outcome measures for chronic cutaneous ulcers and burns are in evolution, as understanding of pathophysiology and techniques for wound treatment and assessment advance.”98 Recognizing this fact, the FDA invited comments on the Guidance document, including suggestions regarding other appropriate endpoints and assessment tools that should be considered in approving drugs and treatments for chronic wounds. Members of the group For Recognition of the Adult Immobilized Life (F.R.A.I.L.) responded to the request for comment by providing information that established a framework for considering frail elderly adults with chronic nonhealing wounds. F.R.A.I.L. distinguished the frail elderly as a group of patients who require products that focus on comfort, dignity, and improvements in functionality. Product-claim categories were suggested that emphasized symptomatic management of wound-related factors, such as reduction of edema, containment of drainage, and odor control. Monitoring exudation, pain, odor, and quality-of-life indices could be combined into a comprehensive wound scoring profile to help clinicians follow the progress of the nonhealing patient. See Table 6 for details on current as well as proposed nonhealing endpoint claim categories. Product needs. The gaps in chronic wound care management treatments include a lack of products that effectively address three primary areas of symptomatic management. Pain. Products must be developed that provide the following: better topical anesthetics for bedside and out-patient wound procedures, particularly for chronic and cyclic pain associated with chronic wounds; expanded options for the management of xerosis and related pruritus; products that effectively address friction and, thereby, prevent skin deterioration among the bedbound; medications or treatments that effectively improve local circulation; and improved approaches for the treatment of venous insufficiency and associated edema. Infection and/or chronic inflammation. Cytokine or immune mediator products should be developed to reduce the damaging effects of prolonged inflammation. Also, debridement options that reduce excessive granulation tissue without causing further inflammation should be expanded . Odor. There is a need for products that effectively eliminate or minimize odor associated with wound contamination, drainage, or infection. Expanded management options should be developed for fecal and urinary incontinence. Also needed is more flexibility in delivery system options that recognize the wide range of limitations among the frail elderly. For example, medications available in suppository and transmucosal delivery forms should be expanded; simplified but effective drainage control and containment systems should be developed; and an expansion of devices that facilitate optimal independence and sense of dignity should be offered. Regulatory and legal recognition of nonhealing wounds. The recognition of nonhealing objectives for frail elderly with chronic wounds in the presence of an overall diminishing health status must be achieved. Legitimizing nonhealing objectives for chronic wounds of various etiologies would establish a foundation for setting realistic expectations on the part of providers, family members, and patients alike. The inflammatory tone and implicit assignment of fault that currently surrounds the issue of chronic wounds would dissipate with the acceptance of nonhealing objectives. The term unavoidable, as used by Centers for Medicare and Medicaid Services (CMS) (formerly Health Care Financing Administration), assumes that every patient has the same priorities and goals for care regardless of the limitations treatments may place on independence, functionality, and quality of life for the individual patient. Ulcer culpability (avoidable vs. unavoidable) is defined retrospectively by CMS. Determination of unavoidable is based on a facility’s ability to demonstrate that serial interventions were applied and that those efforts failed to prevent the occurrence of breakdown. In order to minimize exposure to a CMS survey finding of an avoidable ulcer, clinicians make choices, expend resources, and raise expectations among patients and families alike, knowing that their efforts are unlikely to succeed. This approach neither provides for the nuanced consideration of each individual’s overall health status nor appreciates that palliative objectives may better serve those frail elderly for whom curative goals and full restoration of health is an unrealistic expectation. Educational challenges. In order to successfully integrate palliative concepts into the management of nonhealing chronic wounds, some major shifts in expectations must be made among healthcare providers, family members, and patients alike. Promotion and application of palliative principles to patients with diminishing overall health status will encourage needed shifts in care planning. In a palliative model, treatments and activities reduce the medicinal emphasis while enhancing opportunities for family interactions. This gives license to include activities that previously would have been considered either contraindicated or, at the least, discouraged. For example, a neuropathic ulcer on the plantar surface of the foot usually requires significant mobility restrictions to avoid weight bearing and encourage healing. For the frail elderly patient who has elected to pursue nonhealing palliative goals, that restriction gives way to the preferences and wishes of the patient or his or her representative. Educational efforts must also recognize the realities of resource limitations within the healthcare system. Limited resources in terms of both trained healthcare providers and technology define the availability of many critical elements needed by the institutionalized frail elderly. The impact that scarce resources have within long-term care institutions is reflected by the current attention scarce resources are given in media, litigation, and grass-root patient advocacy group activities. Sicker immobile patients in nursing homes place an added strain on resources. For the bed bound, standard care currently demands a minimum of two-hour turning schedules for those who are unable to independently change positions. Patients with chronic wounds will almost invariably trigger treatment plans that includes healing or closure objectives, which demand aggressive and usually frequent treatment interventions. Medically managed wounds with goals of closure require both positioning and mobility restrictions that may not be in the best interest of patients when viewed from a palliative perspective. This nondiscriminating demand on the scarce resources of healthcare does not consider the risks or the expected outcome for each individual patient. Communication with family members is another significant educational opportunity. Skin breakdown, especially among the vulnerable and frail elderly, causes great consternation for family members. These wounds can be physically repulsive, which may prevent a level of intimacy and contact that family members and patients crave during illness. Often there is a stigma of neglect attached to chronic wounds, forcing a wedge of mistrust between the family, patient, and the healthcare providers. Mistrust minimizes the communication flow between family and provider. Emphasis is placed on defensive charting that records details of size, wound characteristics, and topical treatments. Discussion of nonhealing objectives are avoided for fear that doing so would confirm a failure of the healthcare system. This hesitation is much like the kind of delay seen with terminally ill patients who are referred to hospice only when death is quite imminent. Educational efforts must target physician caregivers whose practices includes the frail elderly, nurses who manage and recommend the day-to-day treatments for this group, and regulators who oversee the quality of care delivered in hospitals, nursing homes, and community. A comprehensive program will link the key elements of assessment, evaluation, and communication skills related to the management of frail elderly with chronic wounds. As discussed previously, providers must develop standardized criteria from which they can determine the relative value of wound healing to an individual patient. Providers must be given the tools to effectively communicate to the patient and/or family the influences that initially lead to the chronic wound, as well as the anticipated limitations and response to treatments aimed at healing/closure. The consequences of aggressive treatment to the overall well being of a frail elderly patient must be established as legitimate considerations in making the determination to elect nonhealing objectives. Healthcare organizations must spearhead major educational thrusts that educate their constituents about the palliative principles of managing frail patients with nonhealing wounds. Available resources for management must be widely circulated and constantly updated. Family caregiver groups must also be educated, as they will become more and more a scarce resource. The Baby Boomers continue to age, and the societal shift toward an older population continues to reduce the caregiver pool. Tools that support the network of informal caregivers will become an invaluable asset in both maintaining and developing resources, skills, and ability to effectively provide palliative care to the frail elderly. We must study this growing, vulnerable population to more readily recognize the appropriate moment when the application of palliative objectives for chronic wound management should be initiated.