Venous Leg Ulcers in the Elderly Patient: Associated Stress, Social Support, and Coping

  The etiology of venous ulcer disease is multifactorial. Increases in vein pressure predispose persons to edema and subsequent lower extremity ulceration. This phenomena usually occurs secondary to valve incompetence and subsequent failure of the pumping action of the skeletal musculature. Additional factors include microvascular compromise, venous hypertension, history of deep vein thrombosis, family history, obesity, age, and pregnancy.^1,2

  A significant number of venous ulcer patients experience pain (either constant or relating to dressing changes), affecting their quality of life³ and leading to frustration and interference with normal daily activities.⁴ Although research has shown that psychosocial issues in wound management are critical when formulating treatment algorithms, clinicians frequently overlook them. Knowledge of stressors, social support, and coping often can “fill the void” when evaluating these patients and further elucidate the idiosyncrasies of recalcitrant wound pathologies; this is particularly germane to geriatric populations. The purpose of this overview is to provide the most pertinent concepts/models and research relevant to caring for lower extremity wounds in the elderly.

Psychosocial Issues

  Numerous psychological theories and models have been crafted to explain the human condition as it relates to health behaviors.⁵ Understanding the Health Belief Model and health locus of control is particularly useful when examining the psychosocial effects of chronic illness.

  The Health Belief Model. Rosenstock et al⁶ originally presented the Health Belief Model to help predict and explain preventative health behaviors; Becker and Maiman⁷ adapted and modified this model specifically to forecast compliance to medical regimens. The prototype suggests that an individual’s motivation to take preventative action depends on health beliefs rather than particular personality traits.⁸ This algorithm utilizes five psychological variables: perceived susceptibility to the disease process, perceived severity of the condition, perceived benefits of taking action, perceived cost of taking action, and internal and external cues to action.⁷

  Health locus of control. Health locus of control, originally described by Rotter,⁹ suggests that behavior is a function of an individual’s belief and may be explained by either an internal or external locus of control that may occur in tandem. Wallston et al¹⁰ describe the existence of an external locus of control when patients believe their health outcomes depend on fate or powerful others. Subsequently, compliance is problematic and these patients usually fail to engage in positive health behaviors.

  Conversely, an internal locus of control assumes that health outcomes are directly related to the individual’s volitional behavior⁸; such patients often take positive steps to improve outcomes.⁹

Psychosocial Effects of Chronic Illness

  Wounds often create profound psychological stress on patients, caregivers, families, and friends. The results of Sapolsky’s¹¹ extensive review of biomedical literature suggest that individuals are likely to activate a stress response, creating increased risk for stress-sensitive disease predicated on feelings relating to 1) minimal control over stressors, 2) concern they have little predictive information about the duration and intensity of the stressor and few outlets for the frustration caused by the stressor, 3) interpretation of the stressor as evidence of a worsening circumstance, and 4) lack of social support.

  Reviewing the historical literature, van Rijswijk¹² proposed that the state of having a wound inferred imperfection, resulting in physical and emotional vulnerability. Wounds often profoundly affect quality of life, including marked restrictions in activities of daily living (ADL)^13,14; pain, edema, fatigue, and bulky dressings may make simple acts such as changing clothes and bathing frustrating or unachievable.¹⁵ Additionally, leg ulcers may interfere with social lives, housework,¹⁶ leisure activities, and mobility.¹⁷

  Many patients, concerned that their wounds are offensive, harbor feelings of isolation relating to ulcer odor and limit social contact (see Figure 1). Roe et al¹⁸ observed increased anxiety and depression scores, lower life satisfaction, and decreased social contacts among patients with malodorous leg ulcers.

  Patients often adapt unnecessary avoidance tactics to minimize the risk of aggravating an existing ulcer or incurring another wound.¹⁹ The stresses and anxiety relating to leg wounds disturb body image; avoidance of activities associated with the problematic body part remain common because they give rise to increased autonomic anxiety and anxiety-provoking thoughts.²⁰ Wound pathologies may create such profound psychological effects that descriptions of the stages of acceptance of altered body image²¹ may parallel unresolved grief associated with the loss of a loved one.

  Pain. Painful venous leg ulcers have been described as “the literal breakdown of the skin and the figurative breakdown of the embodied self.”⁴ Pain appears to represent the most profound symptom of venous leg ulcer disease. Hofman et al²² observed that 69% of 38 patients described pain as the “worst thing” about having the ulcer. A study by Hareendran et al¹⁹ similarly found that 64.9% of patients reported pain. Work by Walshe¹⁵ and Phillips et al²³ yielded parallel results. However, the impact of pain often remains illusive. In a recent study of district nursing practice in relation to leg ulcer management, Roe²⁴ observed 55% of nurses neglected to include questions about pain as part of their assessment. Hollinworth²⁵ found similar results, observing that nurses often failed to assess pain verbally or to use pain assessment tools. In a recent qualitative study of 3,300 questionnaires from three countries (with a 15.1% response rate), Kammerlander²⁶ found only 16% of respondents used a standardized pain scale.

  Generally, pain associated with dressing changes, subsequent wound cleansing, and debridement appear most problematic. Perception of pain remains highly subjective; McCaffery’s²⁷ widely accepted definition of pain as “whatever the experiencing person says it is and existing whenever he says it does” still applies.

  It has been suggested that pain be viewed as the “fifth vital sign,” giving it the same importance as temperature, pulse, and respiration.²⁸ Clinicians should foster the use of visual and more complex assessment tools²⁹ and provide procedures, analgesia, and dressings consistent with pain management. These include controlling the sources of pain, applying topical anesthetics as required,³⁰ and carefully selecting dressings (among other products) that cover the wound bed and exposed nerve endings yet adhere as little as possible, leaving minimal residue behind.³¹ In addition, authorizing patients to perform their own dressing changes facilitates “time-outs” and may further reduce painful symptoms.²⁸

Coping Strategies

  Although the definition of coping may be controversial, this phenomenon may be viewed as a process by which individuals attempt to manage the perceived differences between the demands placed on them and the resources available to deal with those demands.³² Jones³³ contends that an individual’s reactions to emotional stressors remains predicated on his/her unique coping strategies and the interplay among social support mechanisms; patients employ various coping behaviors including denial, acceptance-resignation, and problem-solving.³⁴ Several studies maintain that coping occurs via the process of normalization,^22,35 while others observe adaptation as a key element in this process.³⁶ Walshe¹⁵ elucidates four major coping strategies: coping by comparison, feeling healthy (despite the ulceration), altered expectation (acceptance by viewing the ulcer as part of the aging process), and being positive. Conversely, Neil and Munjas³⁷ observe that many patients do not experience normalization and the wound becomes an obsessive and all-encompassing process. Patient perceptions relating to healing and caregivers appear most important when choosing coping strategies.

  Several studies found that older persons coped and adapted to limitations and disabilities better than younger ones^22,38; however, Price and Harding³⁵ take issue with this contention, finding no statistical differences between older and younger persons.

  The Coping Response Inventory (CRI)³⁹ enumerates multiple subscales that represent various coping strategies, identified as cognitive (thinking about the situation), behavioral (attempting to do something about the situation), approach (tackling the situation head on), and avoidance (ignoring the situation). Previous research by Moos and Shaefer⁴⁰ contends that positive adaptation most often stems from the approach strategy.
Clinicians often function under the misconception that all patients possess the desire to heal; however, Myss⁴¹ observes that this contention may be misleading and potentially dangerous. Staying wounded may provide benefits, including continued nursing visits and home health aide services, an excuse to remain unemployed, or continued attention from family and health care providers.⁴² Moffatt et al⁴³ concur, citing the “knitting needle syndrome” — anecdotal evidence of patients tampering with leg ulcer dressings and bandages and delaying healing.

Social Support

  Work by Keeling et al⁴⁴ contends that the support gleaned from family, friends, and others throughout a serious illness remains pivotal in the patient’s adapting to the illness as well as recovering from it. Research by Sosa et al⁴⁵ and Vachon et al⁴⁶ garnered similar results. Yet social support remains difficult to define or measure objectively; descriptions are usually predicated on a wide range of “helping” relationships. Wills⁴⁷ defines the concept as perceived comfort, caring, esteem, or help a person obtains from other persons or groups. Dunkel-Schetter and Bennet⁴⁸ elucidate a hierarchy of social relationships including social integration, social networking, and social support. The latter encompasses both cognitive (perceived social support) and behavioral (actual support) aspects; an individual’s satisfaction with perceived or actual support could influence the effectiveness of that support. Gottlieb⁴⁹ argues that the source of the support is pivotal to the patient’s perceived satisfaction.

  Explanations regarding the impact of social support on health may be provided through the use of theoretical models, potentially supporting behavioral change or altering perceptions of illness. Benefits of social support can be derived from direct or indirect methods. The main effects hypothesis⁵⁰ suggests a direct impact on mental and physical health; thus, providing benefits regardless of the stress levels. Conversely, Cohen and Wills⁵¹ describe the buffering hypothesis, where social support indirectly buffers a specific stressor and is of benefit only during the stressful episode. Positive influences of social support include physiological, psychological (ie, decreasing emotional discord), and behavioral (ie, encouraging healthy behavior) components.^52,53 These concepts are the basis for comprehensive models including those proposed by Gottlieb⁵⁴ and Cohen,⁵⁵ among others; the algorithms explain the relationships between stress and health outcomes by highlighting the importance of patient appraisal, coping, and adaptation.

  Researchers overwhelmingly laud the benefits of social support; this support may provide regular and positive experiences for both care provider and receiver. Conversely, several researchers have noted some profoundly negative effects of social support. Kaplan and Toshima⁵⁶ observe that caring relationships may foster dependency, subsequently hampering the patient’s recovery. Wortman and Conway⁵⁷ contend that caregivers may feel unappreciated, trapped in nonreciprocal yet intensive one-to-one relationships, ultimately hampering the effectiveness of their support. Silver et al⁵⁸ note that feelings of inadequacy could stifle support entirely.

  Keeling et al³² attempted to measure social support gleaned by elderly patients with chronic wounds by applying Gottlieb’s⁵⁴ theoretical model of stressors, coping reactions, and health outcomes. The Utilization of the Inventory of Socially Supportive Behaviors (ISSB)⁵⁹ provided a framework, comprising three types of support: emotional, guidance (ie, advice), and tangible (ie, financial). The results confirmed previous research by Koster and Bergsma,⁶⁰ who observed that most patients perceived less support than they actually had received. Conversely, in a qualitative analysis of older women’s experiences with multiple health conditions, Roberto et al⁶¹ observed that although women were appreciative of family members’ support, at times they received more help and advice than they preferred.

Physiological Response to Stress

  The literature is replete with studies suggesting that marital discord represents a risk factor for morbidity and mortality. Associated enhanced production of proinflammatory cytokines may accelerate a wide range of age-related maladies. Cardiovascular disease, osteoporosis, arthritis, type 2 diabetes, certain cancers, periodontal disease, frailty, functional decline, and delayed wound healing have been linked with over-production of IL-6.^62,63 Furthermore, immunological down-regulation mirrors negative behavior during marital conflict.⁶⁴ This discord leads to further social isolation. Cacioppo and Hawkley⁶⁵ link this behavior to less efficacious repair and maintenance of physiological functioning, including slower wound healing. In patients experiencing marital conflict, Kiecolt-Glaser et al⁶⁶ observed increased levels of epinephrine, norepinephrine, growth hormone, and ACTH. Extrapolating these findings, the stress of coping with the death of a spouse (a frequent occurrence in the elderly population) could produce similar results.

  Sheridan et al⁶⁷ performed animal studies to elucidate the effects of restraint (RST) and social disruption (SDR) on neuroendocrine response and the impact on wound healing; 3.5-mm cutaneous punch biopsies were created on the dorsal surfaces of control and stressed (RST or SDR) C57BL/6 male mice and studied over 10 days. Subsequent evaluation revealed that RST slowed wound healing; however, wounds on SDR mice healed in similar fashion to non-stressed, home-caged mice. Animal studies, however, cannot be used to extrapolate generalizations; positive results from animal models often fail to yield statistically significant results in humans.⁶⁸ Clearly, studies involving humans would further substantiate this hypothesis.

Compliance

  Compliance issues pervade the population of individuals with wounds; however, these concerns appear to be particularly prevalent in patients with venous and diabetic foot ulcers. Research by Sarafino⁶⁹ demonstrated that average medication adherence rates were 78% for patients with acute illnesses and 54% in patients with chronic illnesses, such as venous hypertension.

  Harker⁷⁰ substantiated these findings relative to adherence with compression hosiery in this patient group. Researchers agree that non-adherence may lead to re-ulceration, culminating in associated costs and risk of increased patient dependency.⁷¹ Mayberry et al⁷² found a 100% recurrence rate within 36 months in venous leg ulcer patients who did not wear compression hose. Patients often refuse to wear compression hosiery, stating they are ugly and uncomfortable. A study by Travers et al⁷³ echoes these concerns; of 32 female patients, 60% said the appearance of compression hose was cosmetically unacceptable. Kemp⁷⁴ revealed comparable findings. Johnson⁷⁵ substantiated patient complaints that these stockings proved difficult to don and remove; older people may be disadvantaged by limited manual dexterity.⁷¹ Although these studies do not condone non-compliance, they establish a generalized pattern of behavior in this patient group and explain a need for a treatment and/or behavioral change. Moneta et al⁷⁶ agree — patient dissatisfaction with treatment and restrictions resulting from bandaging protocols suggests a need for less cumbersome treatment regimens.

  When the patient’s spouse facilitates clinic appointments, the patient often comes late or misses them altogether. In such instances, research suggests that clinic attendance improves if the patient organizes his/her own appointments (Sarafino⁶⁹ and DiMatteo⁷⁷). Therefore, simply altering this dynamic may reverse this trend.

  Strong links exist between locus of control and patient concordance — eg, patients often maintain a belief in external control (“my doctors will make me better”), which may place constraints on their abilities to alter a lifestyle behavior believed to be beyond their control,⁷⁸ potentially leading to non-compliance.

  Seminal research culminating in Ley’s Model of Compliance⁷⁹ represents a triad involving understanding, memory, and satisfaction. The literature, however, contains many studies that may make this model difficult to achieve in clinical practice. Roe²⁴ determined that almost 20% of patients could not remember or did not know the cause of their ulcer and over half did not want any further information concerning their illness. Ley’s⁷⁹ review of the literature substantiated these contentions — between 7% and 53% of patients acknowledged failure to possess an understanding of what they were told. A study on patient perceptions of chronic leg ulcers by Hamer et al⁸⁰ paralleled Roe’s work — 55 out of 88 patients did not want any more information than they had already received about their ulcerative condition. Furthermore, Hareendran et al’s qualitative study¹⁹ of 38 patients concluded that half were dissatisfied with available treatments.

  Compliance, therefore, necessitates a partnership between the patient and clinician⁸¹; health-related behavior should be viewed from the patient’s perspective and the clinician should empower the patient to achieve this goal.⁸² This includes a less authoritarian clinical approach, involvement of family members and friends,⁷⁰ and utilization of a disease-specific, health-related quality of life questionnaire/index to further elucidate patient needs. Detmar et al⁸³ observed that a “health-related quality of life” (HRQL) assessment increased physician awareness of patient emotions and could facilitate physician-patient communication, potentially leading to improved clinical outcomes.

The Clinician’s Role in Patient Compliance/Communication

  Communication is the foundation of all interactions, especially “healing” relationships.⁸⁴ Positive physician-patient relationships are critical to the healing process, improve patient compliance, and foster better clinical outcomes.⁸⁵ Curtis et al⁸⁶ observed that a patient’s emotional state influenced perception of physician communication effectiveness — the greater the patient’s level of depression, the poorer the communication rating. Anectodally, elderly patients with chronic diseases, including those with chronic wounds, often fall into this category, making meaningful communication tenuous.

  Kim et al⁸⁷ noted that patient satisfaction and treatment compliance related directly to physician empathy; a “sense of partnership” created the strongest impact while “information sharing” created little effect on patient satisfaction and actually had a negative impact on compliance. Zachariae et al⁸⁸ agreed that attentiveness and empathy predict patient satisfaction.

  Beck et al⁸⁹ identified behavioral traits that would either promote or hinder patient satisfaction. Positive verbal performance included empathy, courtesy, attentiveness, and encouragement, among others. Physician behavior associated with reduced patient satisfaction included excessive focus on medical questions, showing tension or anger, an unduly dominant approach, and directive behaviors, among others. Bedell et al⁹⁰ suggest physicians foster the use of precise “everyday language” (avoiding potentially disturbing metaphors) that clarifies patient priorities, stimulates inclusion of family members to interact with anxious patients, and reinforces verbal messages with non-verbal behavior.

Gaps in the Literature

  Unlike the quantitative research associated with randomized controlled trials, most studies relating to psychosocial issues are based on qualitative analysis; hence, results may be biased relevant to subjectivity and limited external validity if these considerations are not addressed in the study design, methods, and analysis. Important nuances concerning educational levels, ethnicity, and socio-economic status often are overlooked.⁹¹ Keeling et al⁴⁴ suggest research relating to social support contains inherent deficiencies relative to recording interventions and measuring outcomes. Additionally, coping remains extremely variable; Keeling also contends that the study of this dynamic may not lend itself to standardization without losing meaningful information. Harker⁷⁰ points to potential limitations of the Health Belief Model — patients who fail to consider their physical well-being a priority may express no interest in changing individual health-related behavior. Furthermore, relationships/interactions between patients and clinicians may not be based on equality or mutual respect, leading to inappropriate conclusions and gaps in the literature as well as care.

Conclusion

  Psychosocial issues involving elderly patients are important in the holistic treatment of chronic wounds. Perceptions remain at the core of this process as they relate to pain, body image, coping strategies, and social support. Many emotional variables may exist in tandem, including the internal and external locus of control.

  Clinicians overwhelmingly embrace social support as a positive dynamic; however, this support may have deleterious effects, including fostering patient dependence, caregiver depression, and marital discord. Although results are controversial, older persons may cope and adapt to limitations and disabilities better than younger ones. Physiological effects may be profound, leading to delayed wound healing and exacerbation of illness. Compliance often requires a partnership between the patient and clinician; health-related behavior should be viewed from the patient’s perspective and the clinician should promote patient empowerment to achieve this goal. Foremost, patients with positive health attitudes usually progress toward normalization and adapt to their limitations.

This paper was written as part of the requirement for the PG diploma/MSc in Wound Healing and Tissue Repair, Cardiff University, University of Wales, UK.