Exploring Social Isolation of Leg Ulcer Patients

Wounds isolate people from loved ones  and prevent normal activities. The resulting feelings of loneliness or social isolation greatly matter to patients¹ and may profoundly reduce quality of life, health, and mood, especially in elderly individuals.² Social isolation can extend the length of hospital stay³  or predict an individual’s earlier transition from independent community living to a long-term care institution,² which increases economic and social burdens. There is scant evidence to inform decisions about efficacy or safety of practical interventions to remedy social isolation,^2,4 as this outcome is not a focus mandated by registration authorities.^5,6 This Evidence Corner reviews research on how to identify and quantify the effects of social isolation on those with chronic leg ulcers.⁷ In addition, how a team-based, patient-focused coaching remedy for social isolation has improved economic and healing parameters and restored quality of life^8,9 for those with chronic leg ulcers is also discussed herein.

Reference: Kouris A, Armyra K, Christodoulou C, Sgontzou T, Karypidis D, Kontochristopoulos G, Liordou F, Zakopoulou N, Zouridaki E. Quality of life psychosocial characteristics in Greek patients with leg ulcers: a case control study [published online ahead of print September 12, 2014]. Int Wound J. 2016;13(5):744–777.

Rationale: Social isolation is a common issue for patients with a leg ulcer, which restricts their ability to work and engage in social activities.

Objective: Compare self-reported social isolation, loneliness, distress, anxiety, depression, self-esteem, and quality of life in patients with a leg ulcer to that of healthy gender- and age-matched volunteers.

Methods: After appropriate institutional review, this case-controlled study enrolled 102 consenting patients > 18 years of age who were referred to a Greek hospital for a leg ulcer that had not been treated during the prior 3 months. Those with a psychiatric condition or history of psychotropic drugs were excluded. Each patient enrolled from January 2012 to December 2012, was examined by 2 independent nonstudy investigators and answered all questions on 4 validated questionnaires measuring quality of life (DQLI: Dermatology Quality of Life Index), anxiety and depression (HADS: Hospital Anxiety Depression Scale), self-esteem (RSES: Rosenberg Self-Esteem Scale), and social isolation or loneliness (UCLA: UCLA Loneliness Scale [Version 3]). During the same interval, 102 gender- and age-matched unpaid volunteers with no leg ulcer, otherwise meeting the same inclusion and exclusion criteria completed the same questionnaires. Student’s t-test compared mean questionnaire subset scores and Pearson’s correlation coefficient tested associations among variables measured, with a P value — the probability of falsely rejecting the hypothesis of no differences — set at .05.

Results: The patients with a leg ulcer (53% male) were a mean of 62 years of age (range, 34–88 years). Of the 102 subjects, 49 had venous ulcers, 31 had arterial ulcers, and 22 had ulcers of mixed venous/arterial etiology. Those with any type of leg ulcer had elevated anxiety (P = .014) and loneliness scores (P = .029) and slightly, but not significantly, lower self-esteem (P = .069). Among those with a leg ulcer, women tended to score higher for anxiety (P = .027) and loneliness (P = .048) than men. It was difficult to determine whether leg ulceration caused these stressful emotions and reduced quality of life or whether more anxious or isolated individuals were more likely to develop a leg ulcer. 

Authors’ Conclusions: This study confirmed prior UK and US findings of significantly reduced quality of life, self-esteem, anxiety, and social isolation in those with a leg ulcer. Integrating psychological and social support is recommended to offer these patients relief from isolation and opportunities to share common experiences.

Reference: Edwards H, Courtney M, Finlayson K, Shuter P, Lindsay E. A randomised controlled trial of a community nursing intervention: improved quality of life and healing for clients with chronic leg ulcers.
J Clin Nurs. 2009;18(11):1541–1549.

Rationale: The Leg Club model of managing venous ulcers has improved levels of venous ulcer-related pain and healing after 12 weeks of care compared with traditional home management, but the effects of longer periods of time have not yet been compared.

Objective: Compare quality of life, morale, depression, social support, self-esteem, healing rates, pain, and functional ability outcomes for clients with a venous leg ulcer following 24 weeks of care using the Leg Club model or traditional home care in a randomized controlled trial (RCT).

Methods: After appropriate ethical approval and informed patient consent, 67 clients with an ankle-to-brachial systolic blood pressure ratio of 0.8–1.3 referred to the Brisbane or Gold Coast, Australia, community nursing services for venous leg ulcer care were randomly assigned to receive weekly care by the same team of expert-trained nurses during home visits (control, n = 33) or during visits to a Leg Club (n = 34). Both groups received an evidence-based protocol of care consisting of (1) comprehensive health assessment; (2) circulatory referral as needed; (3) evidence-based short-stretch compression bandage, wound, and skin care; (4) advice and support regarding venous ulcers; and (5) follow-up management and preventive care. Leg Club clients received added peer support, social interaction, goal-setting advice, and refreshments in an open-space, community-owned setting, with separate dressing stations where attendees could communicate with each other and attending professionals. Trained volunteers provided transport for clients unable to travel independently to the Leg Club. For both groups, data were collected on enrollment and 12 and 24 weeks later including: wound area calculated from tracings, clinical infection signs, venous eczema, edema, wound bed tissue type, and patient-reported ratings from age-appropriate standardized questionnaires of quality of life, pain, functional ability, depression, morale, self-esteem, and social support. Intent-to-treat analyses using appropriate Z-values, chi-square or Mann-Whitney U tests were conducted with a one-tailed criterion for significance of P = .05. Small group sequential analysis with standard errors adjusted for comparisons across time. Wide variability of ulcer areas called for log transformation before analyses. 

Results: Leg Club and Control clients were similar on all parameters at enrollment and lost similar numbers to follow-up by week 24, when each group had 26 remaining clients. By week 24, clients had generally improved in most parameters. Clients in the Leg Club group reported significantly more improvement compared with the control clients’ on all parameters studied except for depression (P = .227) and perceived social support (P = .150). At 24 weeks, 15 (60%) of Leg Club clients and 10 (40%) of control clients’ venous ulcers were completely healed (P = .157). Wide variability and small sample size prevented percent area reduction from differing significantly between groups. However, log₁₀ ulcer area decreased more in the Leg Club group from a baseline mean of 7.9 cm² to 1.54 cm² at 24 weeks, compared with 8.3 cm² at baseline decreasing to 6.2 cm² at 24 weeks for Control clients (P = .004). 

Authors’ Conclusions: The Leg Club model is appropriate and effective in improving quality of life and healing in clients with chronic leg ulcers. 

These 2 studies clarify the role of social isolation in leg ulcer management as an important and consistent outcome to measure in studies on leg ulcers⁷ and as an environmental variable to reduce in the effort to improve leg ulcer healing and quality of life outcomes.⁹ As Edwards et al⁹ point out, using the Leg Club model to reduce social isolation enhanced outcomes beyond those observed in response to the same standardized, evidence-based leg ulcer management practiced by the same nurses in patients’ homes. A limitation of this RCT trial is its small sample size. Among the 146 subjects evaluated for inclusion in the Leg Club study⁹ about 1 in 3 clients (n = 36) were excluded due to an inability to attend the Leg Club. One wonders what similar options are open to these home-bound clients. Remote coaching, counseling, and mentoring of less trained home caregivers provided by more expert nurses using evidence-based clinical practice guidelines is not only feasible, but has improved healing and economic outcomes of a variety of acute and chronic wounds compared to matched historic controls.¹⁰ Follow-up of clients with a history of leg ulcers using remote physical activity coaching has been reported as feasible and acceptable to patients with a history of leg ulcers.¹¹ Perhaps it is time for society’s notable advances in communications to be put to work in reducing social isolation for patients most in need. Although RCT evidence is sparse, in this age of patient-centered wound care it is clear that social isolation merits further research and measurement as an important patient concern. In addition, its reduction may provide clinical and economic benefits by improving patient and wound care outcomes.