Guest Editorial: The Challenges of Geriatric Care

   Many geriatric patients will develop wounds that heal slowly or fail to heal altogether. Structural changes associated with aging of the skin may predispose persons to poor wound healing. In the epidermis the dermo-epidermal junction may flatten and the number of melanocytes and Langerhans’ cells may decrease, leading to cyto-architectural disarray. In the dermis, vascularity and density decrease and the function and number of sweat glands in the appendages are reduced; also, a loss of melanocytes occurs.¹ Epithelialization rates may decline and keratinocytes may exhibit age-related reductions in mitogenic response to various growth factors, culminating in increased sensitivity to negative growth modulators.²

   With the groundswell of baby-boomers entering the geriatric sector, continually challenging cases will be the mainstay of the wound healing practice. Many potential wound etiologies exist, including sequelea from diabetes, venous and arterial disease, pressure, and trauma. A host of other conditions may predispose patients to wounds, including renal failure, Crohn’s disease, rheumatoid arthritis, and anti-phospholipid antibody syndrome. Diagnosis of wound malignancy, however, often remains elusive. This is particularly critical in the geriatric population; the typical age for presentation of squamous cell cancer is 70 years. Foremost, clinicians must recognize subtle signs and symptoms and recommend biopsies to substantiate clinical markers.³ In this issue of Ostomy Wound Management, Drs. Perrotto and Glick discuss cutaneous malignancies that may masquerade as ulcers as well as a photographic compendium of many of these conditions.

   Many nutritional deficiencies present with alterations in the skin or in healing.⁴ Dr. Zulkowski addresses the numerous physical, psychological, and socio-economic factors that may predispose the elderly to decreased nutritional status and the need for a transdisciplinary approach to care. Dr. Camden and Judy Gates elucidate the problems associated with obesity in the geriatric patient and provide management options for these individuals.

   Falls represent a significant problem for elderly patients, culminating in rising mortality and morbidity. Dr. Aronovitch discusses this dilemma within the context of patient safety and outlines new government guidelines for long-term care facilities.

   For these informative articles and those in Part 1 of the Geriatric issue, I extend my sincere thanks and appreciation to the contributors. Your efforts, specialized knowledge, and perspectives were truly outstanding.

   We live in an exciting era. Someday, we will have the ability to utilize genetic engineering and perhaps stem cell therapy to heal difficult wounds in all ages. Hang onto your hats and enjoy the ride!

Professionally,
Robert J. Snyder, DPM, FACFAS, CWS

This article was not subject to the Ostomy Wound Management peer-review process.

1. Desal H. Ageing and wounds. Part 2: healing in old age. J Wound Care. 1997;6(5):237–239.

2. Ratzen SIS. Altered cellular responsiveness during ageing. Bioassays. 1991;13:601–606.

3. Snyder RJ. Skin cancers and wounds in the geriatric population. Geriatr Dermatol. 2006: In press.

4. Ueno C, Hunt TK, Hopf HW. Using physiology to improve surgical wound outcomes. Plast Reconstr Surg. 2006;117( suppl):59S–71S.