Optimal treatment of venous (stasis) ulcers in elderly patients

Venous, Arterial, and Neuropathic Leg Ulcers With Emphasis on the Geriatric Population

Leg ulcers are a common and often serious problem in older adults. Underlying conditions that increase risk include age-related increases in chronic venous insufficiency, peripheral artery disease, connective tissue and autoimmune conditions, reduced mobility, and diabetes mellitus (DM). Geriatric patients have a higher risk of multiple wound-related complications including infection, cellulitis, ischemia, and gangrene, any of which may lead to further complications including amputation. The very presence of these lower extremity ulcers in the elderly negatively impacts their quality of life and ability to function. Understanding and early identification of the underlying conditions and wound features are important for effective ulcer healing and complication mitigation. This targeted review focuses on the three most common types of lower extremity ulcers: venous, arterial, and neuropathic. The goal of this paper is to characterize and discuss the general and specific aspects of these lower extremity ulcers and their relevancy and impact on the geriatric population. The top five main results of this study can be summarized as follows. (1) Venous ulcers, caused by inflammatory processes secondary to venous reflux and hypertension, are the most common chronic leg ulcer in the geriatric population. (2) Arterial-ischemic ulcers are mainly due to lower extremity vascular disease, which itself tends to increase with increasing age setting the stage for an age-related increase in leg ulcers. (3) Persons with DM are at increased risk of developing foot ulcers mainly due to neuropathy and localized ischemia, both of which tend to increase with advancing age. (4) In geriatric patients with leg ulcers, it is important to rule out vasculitis or malignancy as causes. (5) Treatment is best made on a case-by-case basis, considering the patient's underlying condition, comorbidities, overall health status, and life expectancy.

A point prevalence audit of inpatients with leg ulcers eligible for compression therapy in a large university NHS hospital

OBJECTIVE

Compression therapy is the mainstay of treatment for venous leg ulceration. Several studies have evaluated leg ulcer management and compression in the community. However, little is known about the leg ulcer population and use of compression therapy in the hospital setting, where it is not often part of inpatient care. This study aimed to evaluate the proportion of inpatients with leg ulceration eligible for compression therapy.

METHOD

A point prevalence audit was undertaken using three methods: patient electronic live report; a leg ulcer audit form; and an electronic record search. The following data were retrieved: patient age, sex, primary reason for admission, diabetes, mobility status, history of dementia, Clinical Frailty Scale score and presence of oedema. Ankle-brachial pressure index was measured to determine patients' eligibility for compression therapy.

RESULTS

The audit identified 80/931 (8.5%) inpatients as having confirmed, active leg ulceration. A total of 36/80 (45%) inpatients were assessed for eligibility for compression, of whom 25/36 (69.4%) were eligible for full compression, 2/36 (5.6%) reduced compression and 9/36 (25%) were not eligible for compression therapy.

CONCLUSION

The audit demonstrated that a significant proportion of hospital inpatients with leg ulcers were eligible for compression therapy and that this patient population were heterogenous in terms of comorbidity profile, mobility, frailty and dementia, among other factors. Further research is required to explore the most feasible and effective compression options for inpatients with leg ulcers.

Controlled, randomized clinical trial of 2 hydrocolloid dressings in the management of venous insufficiency ulcers

A prospective, randomized study was conducted to compare the performance of 2 hydrocolloid dressings, hydrocolloid A and hydrocolloid B, in the treatment of venous insufficiency ulcers. A total of 31 patients were enrolled at 2 clinical sites. Complete wound closure (100% epithelialization) was observed in 59% of the patients treated with hydrocolloid A, compared with complete wound closure in 15% of the patients in the hydrocolloid B group (P <or=.03). Investigators also rated hydrocolloid A significantly better in ease of application, adhesion, conformability, exudate absorption, barrier properties, transparency, and patient comfort (P <or=.02). Significantly fewer patients in the hydrocolloid A group required unscheduled, product-related dressing changes (P <or=.02). In this clinical study, hydrocolloid A demonstrated excellent performance characteristics and was highly effective in treating venous insufficiency ulcers.

Paste-impregnated bandages

A review of the uses of bandages impregnated with paste and their application in the treatment of leg ulceration.

Randomized, double-blind, placebo-controlled, dose- ranging study of granulocyte-macrophage colony stimulating factor in patients with chronic venous leg ulcers

Chronic venous leg ulcers are a common ailment with no ideal treatment. Recent reports have shown granulocyte- macrophage colony stimulating factor to be of use in the healing of these chronic wounds. Therefore, we conducted a double-blind, randomized, placebo-controlled study which enrolled 60 patients with chronic venous leg ulcers, whom we treated with placebo or with 200 or 400 microg of granulocyte-macrophage colony stimulating factor by perilesional injections of the drug in four weekly treatment episodes. Observations were conducted at each treatment visit, at weeks 5, 9, 13, and six months after the inclusion in the protocol. The number of healed wounds in the placebo and the treated arms were significantly different (p = 0.05), with 4 of 21 (19%) in the first group having healed at week 13, as compared to 12 of 21 (57%) and 11 of 18 (61%), in the 200 microg and the 400 microg groups, respectively. There were only minor side-effects attributable to the treatment, and the reobservation at 6 months showed that none of the treated ulcers recurred during that period. We conclude that granulocyte-macrophage colony stimulating factor injected perilesionally may be a useful drug for the treatment of chronic venous leg ulcers.