Skin Failure: Identifying and Managing an Underrecognized Condition : Page 2 of 2
As pressure ulcers and skin failure are not the same, there is a need to develop tools that can predict skin failure. With a pressure ulcer, it is only after the ulcer develops that quality assurance initiatives determine avoidability.13 Two European studies aimed to develop pressure ulcer risk assessment scales in palliative care settings.18,19 Of these tools, the most promising was the Hospice Pressure Ulcer Risk Assessment (HoRT) scale,19 which includes physical activity, mobility, and age in its assessment. In a study of 85 subjects in a palliative care ward, the HoRT scale had a 100% sensitivity (100% negative predictive value) and 75% specificity (50% positive predictive value) for predicting a pressure ulcer. The scale remains to be validated in other settings, including in frail older adults in LTC.10
Another palliative care study showed that factors such as male sex, an inability to lie flat, catheter use, ostomy care, and an inability to perform activities of daily living are associated with pressure ulcers in home care residents with terminal cancer.20 For those LTC residents who are frail or have chosen a palliative pathway of care, a more sophisticated tool for the prediction of skin failure is needed. Presumably, such a tool would help staff educate residents’ families about the realistic expectations of skin changes during end-of-life care.
Comorbidities and Skin Failure in LTC
Langemo and Brown4 described three types of skin failure: acute, chronic, and end-stage. They reported that most episodes of skin failure in LTC settings are either chronic or end-stage. In chronic skin failure, the resident must have a chronic disease and exhibit a steady decline associated with aging or the progression of his or her disease. Dementia is a common chronic illness in LTC.21 Advanced dementia is frequently associated with complications in its last stages, such as impairment in nutritional status, loss of fat and muscle, pneumonia, and febrile episodes.22,23 As this and other chronic diseases cause slow organ failure, blood is shunted away from the skin, which eventually fails. In end-stage skin failure, the resident experiences more rapid skin failure that is concurrent with the end of life. As in chronic skin failure, blood is diverted to the vital organs as the final effort to preserve internal organ function. The resulting skin breakdown can be shocking to both staff and family members. Honest, open communication about the prognosis is therefore important at this time.
Prior to starting interventions, staff caregivers should be fully aware of residents’ comorbid conditions that may hamper efforts to maintain nutrition and hydration. In the last months of Alzheimer’s dementia, a terminal illness, eating problems will begin.24 Those patients with dementia and skin failure will require a family discussion regarding the use of a feeding tube. No data show, however, that feeding tubes improve nutritional status or resolve pressure ulcers in the setting of end-stage dementia.25 Despite the lack of data, families may find it challenging to watch their loved ones “waste away” with failing skin. Providers and dietary and speech therapists must continue to support families in the decision-making process. Nursing staff, including certified nursing assistants, can educate families about the pleasures of hand-feeding their loved ones.26
Managing Skin Failure in LTC
Similar to other chronic wound conditions, skin failure necessitates an interdisciplinary approach. In the LTC setting, these specialists should be readily available. Providers, nursing staff, dietitians, rehabilitative therapists, and the resident and caregivers all play a role in the resident’s care (Figure). Whereas pressure ulcer care is aimed at reversing the underlying condition, skin failure care should be focused on resident-centered and caregiver-centered concerns.9
Providers need to have frank discussions with the resident and his or her family, significant other, or caregivers regarding the resident’s prognosis, treatment of symptoms, and goals of care. In turn, residents and caregivers must be willing to clarify the goals of care. Several discussions may be necessary to help them through this process.27 A palliative care or hospice team, if available, can be invaluable in establishing a prognosis, educating the resident and his or her family, and treating the resident’s symptoms.
Skin failure, like other wounds, will produce significant pain for the resident. Pressure ulcer pain is thought to have both nociceptive and neuropathic mechanisms.28 The provider must assess whether the pain is noncyclic acute (eg, associated with debridement), cyclic acute (eg, associated with hygiene, turning regimens, dressing changes), or chronic.29 Both pharmacologic and nonpharmacologic means should be used to alleviate the pain, depending on its type and duration. The certified nursing assistant can alert the team to any changes in the resident’s pain experience, such as grimacing or moaning that occurs during the resident’s hygiene or turning regimen. Rehabilitative specialists can educate the team about repositioning the resident as well as recommend off-loading devices to help relieve pressure and pain.
A pressure ulcer will push a resident into a catabolic state, thereby increasing his or her nutritional and hydration needs.30 A dietitian can calculate the necessary amount of calories and fluid that the resident would require for healing, if healing is considered possible. Adequate calories, in addition to protein, are needed to promote collagen and connective tissue synthesis.31 If only protein is supplied without adequate calories, then the protein will be used as an energy fuel.
The mainstay of chronic wound management is moist wound healing. In the case of skin failure, where healing may not be possible, moist wound healing may increase the bacterial burden and risk of infection.32,33 In these situations, povidone-iodine and other antiseptics may be beneficial in preventing wound deterioration or worsening, but these agents have been prohibited in healthcare facilities because of their reported cytotoxic effects. Two systematic reviews, however, have suggested that there is still a role for antiseptics in the treatment of nonhealable wounds.34,35 The resident’s prognosis, goals of care, and ability of the wound to heal must be continuously documented to enable the use of such a controversial product. When antiseptics are used, care must be taken to prevent the wound from overdrying, which can cause increased pain with dressing changes. Wet-to-dry dressings are not recommended,8 as they are especially problematic in patients with skin failure, leading to increased nursing burden and worsening pain for the resident, while providing no bacterial balance.36,37 The recommended dressings are those that are nonadhesive, absorptive, and odor-controlling; prevent desiccation of the wound bed; protect the periwound from maceration; and can be left in place for longer periods. Examples of these dressings include hydrogels, foams, polymeric membrane foams, silicones, and alginates. Odor can be counteracted by removing necrotic debris and using antimicrobials, activated charcoals, and a variety of external odor absorbers.8,38
Because of the dearth of clinical data regarding skin failure, it can be difficult to determine the difference between a pressure ulcer and skin failure. This can be problematic when LTC facilities face increasing liability along with an increasing incidence of pressure ulcers.Skin failure is not a “permissible” pressure ulcer,and research efforts must therefore be focused on a better understanding of this phenomenon.
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The authors report no relevant financial relationships.
Address correspondence to:
Elizabeth Foy White-Chu, MD
Department of Medicine
1200 Centre Street
Roslindale, MA 02131