Wounds in Older Age: More of a Problem?

As our population ages, it has been said that chronic wounds are becoming more common and more difficult to heal.¹ Though I am definitely “aging,” I do not seem to be having problems healing operative wounds or other minor wounds I tend to acquire. One of the first questions we need to address is, how old is old? Most researchers are not brave enough to wade in that lake, but Wicke and colleagues have implied that age-related wound healing problems begin to appear when the patient is 70 years of age or older.² What are the problems that can cause this delayed healing? According to a recent publication, it appears that skin changes and medical comorbidities are significant contributing problems that can make wounds harder to heal.³

Skin changes that impact wound healing include decreased elasticity of the skin, decreased moisture content of the skin, atrophy of the dermis, decreased adhesion of the epidermis and dermis, decreased number of fibroblasts resulting in altered extracellular matrix production and maintenance, decreased responsiveness of keratinocytes to growth factors, and up to a 35% decrease in the number of capillaries.^3,4 In addition, a decreased number of Langerhans cells, reduction in endothelial nitric oxide production with associated loss of capillary permeability, and decreased neutrophil migration and phagocytosis add to the increased possibility of infection and reduced wound healing in older individuals.^5,6 It has also been suggested that a failure of macrophages to evolve from the pro-inflammatory phenotype to the anti-inflammatory phenotype results in a continued inflammatory wound environment not conducive to healing.⁷

The presence of comorbidities, obviously, increases with age. Everyone is familiar with the problems diabetes causes in healing. Unfortunately, many persons of advanced age (“seniors”) have diabetes, and the disease can cause more problems with healing in older patients than in the young. Generally, obesity is not thought of as a problem in that population, but data show that more than one-third of the population over age 65 is obese.³ Other associated diseases are frequently seen in this age group which can influence healing as well as can the treatments for these diseases.

As treatment is considered for these older patients with wounds, where does the provider start? Of course, all wounds should be treated with the basics of wound care in which the underlying conditions are minimized, the wound bed is protected from the trauma of caustic therapies and inappropriate dressings, an appropriate moisture balance is assured, bacterial bioburden and biofilm are addressed, appropriate debridement is done, and edema and lymphedema are controlled. After this, the special needs of the wound must be considered as the provider tries to find solutions to an inflammatory wound environment, senescent cells, and other issues. Using currently available advanced therapies (such as growth factor therapy or skin substitutes) that will meet the special needs of the “senior” wound should be considered earlier in treatment. Interestingly, it has even been reported that topical estrogen cream can be helpful in healing wounds in all older patients.⁸

Until more research is conducted to better define the needs of the “senior” wound and appropriate therapies are developed, providers must use all currently available tools to assure the best care for these patients.

Terry Treadwell, MD, FACS
Editor-in-Chief, Wounds

woundseditor@hmpglobal.com