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Nutritional Factors for Wound Healing in the Older Adult Patient

There are seemingly countless factors that contribute to increased risk for the development of pressure injuries among certain patient populations. For those who require a stay in long-term care, the incidence of pressure injuries can be a concern. Conditions that contribute to increased risk for pressure injury development include (but are not limited to) diabetes mellitus, peripheral vascular disease, malignancy, prolonged pressure on an area of the body, being 70 years of age and older, smoking, urinary and fecal incontinence, a history of pressure injury, a low body mass index (BMI), and undernutrition.1 When patients require skilled care in the long-term setting and outpatient care in the wound clinic, a collaborative approach to skin care and nutrition is warranted for better care planning and wound care management. Research has shown that 80% of pressure injuries develop within two weeks of admission into a post-acute care facility and that 96% develop within three weeks of admission.1 This article will educate outpatient clinicians on how their involvement with the older patient population can improve outcomes when transfers to and from a skilled care facility are necessary. 

The Integumentary System
The largest organ in the body, the integumentary system (ie, skin) is composed of hair, nails, and sweat and oil glands.2 Aside from serving as a shielding barrier against heat, light, injury, and infection, the skin normalizes body temperature, stores water and fat, and serves as a sensory organ.3 The skin is composed of three layers: the epidermis (outermost layer), dermis (inner layer), and hypodermis. The epidermis provides a waterproof barrier and creates skin tone. The dermis contains tough connective tissue, hair follicles, and sweat glands. Lying below the dermis, the hypodermis is composed of fat and connective tissue.3 The epidermis is a thin, avascular layer that regenerates every 4-6 weeks and contains five tiers: 

1. Stratum corneum: can be easily removed during bathing or scrubbing the skin; protects against entrance of foreign substances and the loss of fluid from the body. 

2. Stratum lucidum: present only on the palms of the hands and the soles of the feet. 

3. Stratum granulosum: also known as the “granular layer;” is 1-3 cells thick.

4. Stratum spinosum: multi-sided cells. 

5. Stratum basale: contains melanocytes. 

The dermis is the middle layer of the skin. As the thickest skin layer, it contains blood vessels, lymph vessels, hair follicles, sweat glands, collagen bundles, fibroblasts, and nerves. The dermis provides the skin with flexibility and strength.3 It also contains touch and pain sensors. The hypodermis is the deepest layer of the skin and consists of a network of collagen and fat cells that help conserve body heat and act as a shock absorber.3 The blood vessels in the skin dilate and constrict to regulate body temperature. Nerve receptors located in the skin allow us to respond to pain, touch, temperature, and pressure. In the presence of sunlight, ultraviolet rays strike the skin and activate vitamin D synthesis.4 

Aging Changes In The Skin
Changes in the skin are the most visible signs of the aging process. These changes are influenced by genetics, environment, nutrition, and other factors. The skin’s texture changes as we age. The epidermis thins and becomes more prone to skin tears. The skin looks pale and almost translucent.5,6 Alterations in the connective tissue decrease the skin’s strength and elasticity. The blood vessels of the dermis become more fragile. This can contribute to bruising as well as bleeding beneath the skin.5,6 Thinning of the subcutaneous fat layers reduces padding and insulation. This increases the risk of skin injury and can contribute to hypothermia when exposed to cold weather. Decreased body fat accentuates bony prominences and increases the risk for pressure injuries in these areas. Skin loses elasticity as collagen decreases and elastin loses its ability to recoil. With a reduction of sweat glands, we see drier skin that has much slower epidermal regeneration.5,6 One of the effects that occurs as a result of skin changes is the increased risk for developing pressure injuries. Risk factors associated with the development of pressure injuries include skin changes associated with aging, loss of fat layer, decreased physical activity, compromised nutritional status, and the presence of chronic and acute disease processes. When compared with their younger counterparts, skin injuries in older adults can take up to four times longer to heal. This increases the risk for infection. Illnesses such as diabetes, changes in blood vessels, compromised immune system, and other factors can also affect the rate of wound healing.5,6  

Nutrition & The Skin
Nutrition is a major element in promoting health. Food (as a major source of nutrition) is critical to one’s physiological well-being and contributes to social, cultural, and psychological quality of life. As a primary intervention, nutrition helps support health and functionality. As a secondary and tertiary strategy, adequate nutrition is vital to decrease the risk for developing chronic disease, to slow disease progression, and to reduce/control disease symptoms. When a wound develops, individuals should consume additional calories to support the inflammatory process and cellular activity needed to promote skin integrity. Additional calories support new blood vessel formation (angiogenesis) and collagen deposition in the proliferative phase of wound healing while preventing destruction of proteins. Consider the following areas of nutrition:

Macronutrients & Micronutrients 
Meeting macronutrient (protein, carbohydrates, and fats) and micronutrient (vitamins and minerals) requirements is essential for developing a foundation of well-being and healthy skin. This translates to consuming wholesome, nutrient-dense foods. Micronutrients are defined as chemical elements or substances required in trace amounts for the normal growth and development of living organisms. The World Health Organization describes micronutrients as “magic wands” that enable the body to produce enzymes, hormones, and other substances essential for proper growth and development.7 Micronutrients include minerals such as sodium, copper, and zinc (to name a few) and vitamins such as A, B, C, D, E, and K. There are a number of nutrients associated with supporting skin integrity.

Carbohydrates
The body’s main fuel source. As such, carbohydrates provide glucose to support normal cellular activities, protein synthesis, and the secretion of hormones and growth factors. Cellular activities such as production of fibroblasts and leukocyte activity are dependent on adequate intake of carbohydrates.  

Protein
Protein is a key component of immune system cells, such as lymphocytes, leukocytes, and phagocytes. Essential for the activation of macrophages (required for phagocytosis of dead cells and antimicrobial activity), protein consumption is necessary for wound healing.

Arginine
Arginine has been identified as playing a role in wound healing. This amino acid is converted to nitric oxide, which causes blood vessels to expand, thus promoting blood flow. Arginine promotes collagen deposition and wound strength while protecting the immune system.8  

Lipids
Lipids (fats) provide a concentrated source of calories. An essential component of cell membranes, lipids serve as precursors for prostaglandins. This lipid compound regulates many activities in cellular inflammation and metabolism. They are also important for inflammatory cell mediation and clotting elements. 

Fluids
Providing an adequate amount of fluids is as important as providing adequate calories and protein. Water is vital to maintain most body functions. As a major component of blood, water dissolves vitamins, minerals, glucose, and amino acids; transports nutrients into cells; removes waste from cells; and helps maintain circulating blood volume, as well as fluid and electrolyte balance.9

Vitamin A
Vitamin A fuels the formation of granulation tissue and supports the immune system response. It promotes the creation and clustering of monocytes and macrophages in the wound, promotes collagen formation, and guards against side effects of glucocorticoids, chemotherapy, radiation, and diabetes.10 Vitamin A deficiency can lead to immunodeficiency, increased sensitivity to infection, diminished collagen formation, and delayed wound healing.10 

Vitamin C
An antioxidant, vitamin C is needed for collagen synthesis and impacts cell regeneration.  Vitamin C is also required for optimal immune response, cell mitosis, and monocyte movement into the wound tissue. Monocytes transform into macrophages during the inflammatory phase of wound healing.11 Vitamin C promotes iron absorption and increases resistance to infection by promoting migration of white blood cells to the wound. Vitamin C deficiency contributes to increased capillary fragility, decreased wound strength, reduced collagen production, and impaired wound healing.11

Vitamin K
Vitamin K is essential for manufacturing prothrombin and other clotting proteins produced in the liver. These proteins are necessary for the early phases of wound healing. Deficiency in vitamin K can contribute to decreased coagulation. This can interfere with the inflammatory phase of wound healing.10 

Minerals
Copper plays a role in collagen cross-linking that is required for tissue renovation. Iron is important to ensure tissue perfusion. Manganese is needed for tissue regeneration.10 Zinc is an essential mineral found in almost every cell. It plays a role in the production of collagen and cell proliferation. Albumin is the main transport for zinc in the body. As such, the body’s ability to absorb zinc decreases in the presence of decreased albumin levels.10 Zinc deficiency can reduce rates of fibroplasia, epithelialization, and collagen synthesis and weaken wound strength and immune response.10 

Older Adults & Pressure Injuries in Post-Acute Care 
Pressure injuries are a costly and devastating condition. In the United States, 14.8% of patients live with pressure injuries and acute care hospitals treat 2.5 million pressure injuries each year.12  Approximately 60,000 people die every year from the comorbidities associated with hospital-acquired pressure injuries.12 Insufficient consumption of food and fluids contributing to poor nutritional status has been identified as a significant risk factor for the development of pressure injuries and delayed wound healing.13 A Cochrane Review reported that it is unclear whether providing oral nutrition supplements (ONS) reduces the risk of pressure injury development.14 This does not negate the fact that, for individuals identified as at-risk for (or are experiencing) malnutrition, the use of ONS is a viable intervention to bridge the intake-nutritional needs gap. Nutritional risks for developing pressure injuries include unintended weight loss, undernutrition, increased nutrient needs (usually associated with medical conditions), malnutrition, dehydration, decreased BMI, inadequate food and fluid intake, and inability to feed one’s self, among others. Conducting a nutritional screening and a comprehensive nutritional assessment are vital steps in identifying malnutrition and unintended weight loss.13 Factors that can contribute to unintended weight loss and its comorbidities include impaired cognitive status, depression, medication side effects, difficulty swallowing, inflammation, and chronic and acute disease processes. 

CMS Regulations
The Centers for Medicare & Medicaid Services (CMS) requires all post-acute care facilities that receive Medicare funds to provide care and services consistent with established standards of practice to promote the prevention of pressure injury development (unless clinically unavoidable), to promote the healing of existing pressure injuries, and to prevent the development of additional pressure injuries.9 Weight reflects a balance between intake and energy utilization. Significant unplanned weight loss may indicate undernutrition or decrease in health status. Impaired organs, as in the case of heart, lung, and kidney disease, may interfere with the body’s ability to use nutrients effectively. An older adult living with a pressure injury and continued weight loss either needs additional calories or the root cause of the hypermetabolic state needs to be identified and corrected.9 

Guidelines For Prevention & Treatment of Pressure injuries
The National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance have joined forces to publish interprofessional guidelines15 for the prevention and treatment of pressure injuries in adult populations. For individuals living with a pressure injury or are at risk for developing a pressure injury, the NPUAP guideline promotes providing individualized energy intake based on underlying medical conditions and the individual’s level of activity. As a starting point, patients should be provided with 30-35 calories/kg body weight in an effort to provide increased kilocalories. For individuals on a therapeutic diet, the diet should be modified/liberalized when dietary restrictions and limitations result in decreased food and fluid intake.15 When nutritional needs cannot be met with standard dietary intake, the need for fortified foods and high-calorie, high-protein ONS as an intervention should be considered. If nutritional requirements cannot be met with traditional high-calorie and protein supplements, consider supplementation with high-protein, arginine, and micronutrients for adults living with a stage III or IV pressure injury (or those with multiple pressure injuries). Protein should be provided in sufficient amounts to promote positive nitrogen balance. When compatible with the goals of care, 1.25 gm-1.5 gm protein/kg body weight should be provided daily. Adequate fluid intake must be encouraged.15 Consider the use of a daily vitamin/mineral supplement that supplies 100% of daily reference intake,16 if the individual is unable or unwilling to consume a balanced diet that includes good sources of vitamins and minerals, has poor dietary intake, and/or has an identified or suspected drug-nutrient depletion.15

Pressure injury prevention and treatment has been an important element of clinical/nutritional care. Promoting optimum nutritional status is an essential component in the plan of care for patients/residents living with pressure injuries. 

Nancy Munoz is a lecturer at University of Massachusetts Amherst, a freelance writer, and the assistant chief, nutrition and food services, at VA Southern Nevada Healthcare System, Las Vegas. She may be reached at dr.nmunozrd@outlook.com

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Nancy Munoz, DCN, MHA, RDN, FAND
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References

1. Lyder CH, Ayello EA. Pressure ulcers: a patient safety issue. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (US); 2008.

2. Medline Plus. Skin layers. U.S. National Library of Medicine. 2019. Accessed online: https://medlineplus.gov/ency/imagepages/8912.htm 

3. Baranoski S, Ayello EA. Wound Care Essentials: Practice Principles. 4th ed. Ambler, PA: Wolters Kluwer; 2015.

4. National Institutes of Health. Vitamin D: fact sheet for consumers. 2016. Accessed online: http://ods.od.nih.gov/factsheets/vitamind-quickfacts 

5. Medline Plus. Aging changes in skin. U.S. National Library of Medicine. 2019. Accessed online: https://medlineplus.gov/ency/article/004014.htm 

6. Page E. Effects of aging on the skin. Merck Manual. 2017. Accessed online: www.merckmanuals.com/home/skin-disorders/biology-of-the-skin/effects-of-aging-on-the-skin

7. Micronutrients. World Health Organization. 2018. Accessed online: www.who.int/nutrition/topics/micronutrients/en

8. Medline Plus. L-Arginine. U.S. National Library of Medicine. 2018. Accessed online: https://medlineplus.gov/druginfo/natural/875.html

9. State Operations Manual. Appendix PP - guidance to surveyors for long term care facilities. Centers for Medicare & Medicaid Services.  2017. Accessed online: www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

10. Saghaleini SH, Dehghan K, Shadvar K, Sanaie S, Mahmoodpoor A, Ostadi Z. Pressure ulcer and nutrition. Indian J Crit Care Med. 2018;22(4):283-9. 

11. Minutti CM, Knipper JA, Allen JE, Zaiss DM. Tissue-specific contribution of macrophages to wound healing. Semin Cell Dev Biol. 2017;61:3-11. 

12. AHRQ. Preventing pressure ulcers in hospitals. U.S. Department of Health & Human Services. 2014. Accessed online: www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/index.html

13. Posthauer ME, Banks M, Dorner B, Schols JM. The role of nutrition for pressure ulcer management: national pressure ulcer advisory panel, european pressure ulcer advisory panel, and pan pacific pressure injury alliance white paper. Adv Skin Wound Care. 2015;28(4):175-88.

14. Langer G, Fink A. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev. 2014;6.

15. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: quick reference guide. 2014. Cambridge Media: Osborne Park, Australia. Accessed online: www.npuap.org/wp-content/uploads/2014/08/Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-PPPIA-Jan2016.pdf 

16. National Institutes of Health. Nutrient recommendations: dietary reference intakes (DRI). U.S. Department of Health & Human Services. 2019. Accessed online: https://ods.od.nih.gov/health_information/dietary_reference_intakes.aspx

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