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WOUND CARE IN THE ELDERLY

MICHELLE MOMENEE, APRN, FNP-BC, CWS

DISCLOSURES:

EMPLOYED WITH ELLIOT HEALTH SYSTEMS: CENTER FOR WOUND CARE AND HYPERBARIC MEDICINE

WOUND CARE IN THE ELDERLY

Anatomical and physiological changes in the geriatric population that affect wound

healing.

Socioeconomic factors specific to the geriatric population that affect wound healing.

Wound care interventions and approaches best suited to the geriatric population for

wound healing and prevention.

ANATOMICAL AND PHYSIOLOGICAL CHANGES:

SYSTEMIC AND LOCAL

Age related typical changes

Disease associated alterations

Medication effects

Lifestyle effects

SKIN: LARGEST AND MOST VISIBLE ORGAN

15% total body weight

Function:

Thermoregulation

Primary defense structure

Fluid balance

Communication

HEALTHY SKIN STRUCTURES

http://www.proprofs.com/quiz-school/story.php?title=anatomy-and-physiology-questions-the-integumentary-system

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SKIN AGING

Chronological & Photoaging

Senescence and apoptosis

Oxidative metabolism

DNA mutations

Membrane lipid oxidation

Abnormal signaling

Decreased transport

Protein oxidation

Decreased function

AGE RELATED TYPICAL SKIN STRUCTURAL CHANGES

EPIDERMAL

• Thinning

• Flattening of rete ridges

• Slowed cellular turnover rate

• Decreased inflammatory and immune response

• Decreased nerve ending

• Decreased blood vessels in rete ridges

• Decreased melanocytes

• Decreased Langerhan’s cells

• Decreased Merkel cells

• Keratinocytes resist apoptosis

DERMAL & UNDERLYING

Thinning

Flattening of rete ridges

Decreased blood vessels in rete ridges

Redistribution of fat layer

Decreased blood vessels and thinning of vessel walls

Increased # of MMPS’s, decreased # of inhibitors

Elastin and collagen disorganization

Same # of sebaceous glands, hypertrophic and decreased

oil production

Decreased # and function of sweat glands

SKIN ANATOMY

http://www.fpnotebook.com/mobile/Derm/Anatomy/SknAntmy.htm

AGED SKIN

Decreased flexibility, elasticity and strength

Increased reaction to irritants

Decreased antioxidant protection

Impaired sensation, thermoregulation, vascular

reserve

SYSTEMIC DISEASE

Cardiovascular: decreased cardiac output, atherosclerosis, decreased peripheral flow, edema, vessels thin

Diabetes: PAD, decreased immune response, neuropathy, renal impairment, retinopathy

Cancers: chemo and radiation therapy decreases wound healing

Immune: impaired or overactive response

Endocrine: impaired metabolism, impaired communication

Renal: rapidly aging skin and impaired wound healing

Lymph: edema

EFFECTS OF MEDICATIONS

Inhibits Wound Healing

Antiangiogenic chemotherapy

Morphine

Celecoxib (Celebrex) NSAID, ASA, Ibuprofen, Naproxen

Metformin

Singulair

Valium

Dopamine

Lovastatin, simvastatin

Doxycycline, clarithromycin

Furosemide (Lasix)

Warfarin, Apixaban, Rivaroxaban

Corticosteroids, methotrexate

Nicotine

Promotes Wound Healing

Pentoxifylline (Trental)-for venous ulcers

Cilostazol (Pletal)- for arterial ulcers

Currently being studied:

Topical insulin

Topical oxygen

Complementary approaches

(Levine, 2017)

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LIFESTYLE EFFECTS

SMOKING, ETOH, SWEET TOOTH, STRESS SUN DAMAGE

http://www.instructables.com/id/How-to-make-Homemade-Tanning-Oil/

http://www.top10homeremedies.com/news-facts/10-habits-make-age-faster-look-older.html

SOCIOECONOMIC FACTORS SPECIFIC TO THE GERIATRIC

POPULATION THAT AFFECT WOUND HEALING

FINANCIAL

EMOTIONAL

LIVING ENVIRONMENT

FACTS AND NUMBERS

2010 US Census Report:

40.3 million >65 years

13% of the population > 65 years

Health costs of 65 + age group

3 x more than adult

5 x more than child

LIVING SITUATION

SNF/LTC - 3.1 %

ALF – 25%

Group Home: Independent Living

Single Home alone or with Spouse

Single Home with Family Members

INSURANCE COVERAGE

Medicare A

Medicare B

Medicare D – DME’s, pharmaceuticals

Medicaid

Private Insurance

Private Pay

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POVERTY LEVELS IN THE ELDERLY: 2013

US:

15 %, one in seven

Greater in women than in men

3x higher in Hispanic elders

2.5 x higher in Black elders

NH: 14%

20% of elders in poor health, 1 in 5

HISTORY AND PHYSICAL

THROUGH THE SOCIOECONOMIC LENS

Sensory deficits: blindness, HOH, taste, smell, and neuropathy

Mobility deficits: decreased ROM, balance and gait, bending/reaching

Oral health, dental health, functional ability related to shopping/cooking/eating

Functional ability related to bathing, hygiene, self assessment

Assistance: who is available to provide care

Safety risk: alarm sensors, call for help options

INDIVIDUAL COST OF WOUNDS

Painful

Malodorous

Prevents normal daily routine

Time consuming

Costly

Isolating

Depression

Decline in overall QOL

http://www.thinkstockphotos.com/search/#/M||471559232

WHO HAS MALNUTRITION?

Emaciation

Obesity

http://thechroniclesofb.com/?tag=obesity http://www.torontosun.com/2013/05/13/obesity-obsession-overlooks-underweight-kids

NUTRITION AND HYDRATION

Nutrition

Dietary restrictions-medically prescribed

Amino Acids-arginine, glutamine

Vitamins, minerals

Zinc, copper

Anemia

Malabsorption

Enteral or ONS may be needed

Hydration

Fluid restrictions-medically prescribed

Na restrictions-medically prescribed

Swallowing impairments

Acute illness contributing to fluid loss

Monitor weight, skin turgor, urine, serum Na

Medication side effects

Diuretics

Anticholinergics

NUTRITIONAL STATUS

“Screen and intervene”

Affordability?

Eating alone or with others?

Oral health concerns?

Chronic or acute illness affecting appetite, absorption, intake?

mna-elderly.com/forms/mna_guide_english.pdf

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RECOMMENDATIONS

Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition (ASPEN) “do not recommend using inflammatory biomarkers such as serum protein levels for diagnosis of malnutrition.”

Recommends inter-professional care:

Dx medical reasons for altered nutritional and hydration status

Oral health screening

SLP eval-swallowing ability

OT eval-food prep and feeding ability

Dietitian-eval and monitor nutritional status

(Posthauer, 2015)

SPEAKING OF FOOD…….

ELDER ABUSE

Last reported data from 2005, close to 1,500 cases

Abuse

Neglect

Self neglect

Not always malintended

http://www.nhcadsv.org/elder_abuse.cfm

https://www.dhhs.nh.gov/dcbcs/beas/aboutprotection.htm

SOCIOECONOMIC EFFECTS ON WOUND HEALING

Increasing aging population: increasing aging skin

Large percentage require care giving services

Financial constraints restrict ability to afford care

Nutritional deficits increase wound development and delay healing

Fear and embarrassment: wounds under reported until serious illness

Poor skin hygiene leads to increased risk of wound development

WOUND CARE INTERVENTIONS AND APPROACHES BEST

SUITED TO THE GERIATRIC POPULATION FOR WOUND

HEALING AND PREVENTION

SKIN CARE AS PREVENTION

CLEANSING

Mild surfactant

High in phospholipids

Soft cloth

Decreased frequency

Liquid or foam soaps

pH approx. 5.5

Tepid water

MOISTURIZING

Skin barriers:

Dimethicone

Petroleum

Silicone

Restores skin:

Urea

Glycerin

Hyaluronic acid

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HEALING REQUIRES THE SAME PRINCIPALS

FOR EVERY WOUND TYPE

Ensure blood flow

Manage edema and inflammation

Assess for and treat infection

Manage underlying diseases/conditions

Provide nutritional supports and manage hyperglycemia

Remove unhealthy tissue

Provide moisture balance

Off-load to avoid pressure and trauma

Assist patient with financial and social needs

UNMET NEEDS

http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijd/vol1n2/ulcer1.xml

http://rap.genius.com/Jeezy-real-is-back-2-intro-lyrics#note-2642183

http://www.cmaj.ca/content/165/10/1345/F1.expansion.html

http://www.sunrisemedical.com/Products/jay.aspx?producttype=cushions

http://www.worldwidewounds.com/2008/march/Thomas/Maceration-and-the-role-of-

dressings.html

STAGES OF WOUND HEALING

Hemostasis: platelet aggregation, clot formation, stop

hemorrhage, lay a matrix for cell adhesion

Inflammatory: complement cascade, neutrophil &

macrophage response, acute inflammatory response

Proliferative: 3 days to few weeks, proliferation of

fibroblasts, protein synthesis, angiogenesis, granulation

formation, epithelialization

Remodeling: 7 days to one year or more, increases

tensile strength, although never reaches 100%

Stages Illustrated Stages

http://ethesis.helsinki.fi/julkaisut/laa/kliin/vk/vaalamo/fig3.gif

WOUND TYPES

Skin tears

Diabetic foot ulcers

Venous leg ulcers

Arterial leg ulcers

Pressure ulcers

Surgical wounds

Atypical wounds

Edema related

SKIN TEARS: “WOUNDS CAUSED BY SHEAR, FRICTION, AND/OR BLUNT

FORCE RESULTING IN SEPARATION OF SKIN LAYERS

Prevalence studies (more than 10 yrs old) :

LTC-up to 54%

Home setting-up to 19.5%

Acute setting-up to 22%

LeBlanc & Baranoski (2017)

SKIN TEARS: “WOUNDS CAUSED BY SHEAR, FRICTION, AND/OR BLUNT

FORCE RESULTING IN SEPARATION OF SKIN LAYERS

Contributing Factors

Falls and Minor Traumas

Neuropathy

Cognitive Impairment

Thinning Skin and Xerosis

Adhesive Removal

Handling During Care

Edema

Classifications

Partial Thickness-dermal

Full Thickness-sub dermal

ISTAP: International Skin Tear Advisory Panel

2013 Skin Tear Classification System

Type 1: no skin/flap loss

Type 2: partial skin/flap loss

Type 3: complete flap loss

LeBlanc & Baranoski (2017)

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SKIN TEARS: “WOUNDS CAUSED BY SHEAR, FRICTION, AND/OR BLUNT

FORCE RESULTING IN SEPARATION OF SKIN LAYERS

PREVENTION

Avoid tape/adhesive use

PT/OT referral

Protective equipment

Protective sleeves

Moisturizing skin care

Geropsych-cognitive health referral

INTERVENTION

Irrigate

Approximate and secure

No tape with dressing application

Non-adherent dressing

Protective sleeves

SKIN TEAR DRESSINGS: NON-ADHERENT

GERI-SLEEVES: PROTECTION

http://www.rehabmart.com/resizeimage_send.asp?path=/imagesfromrd/ML-

NONSLEEVE%20Protective%20Sleeves_Skin%20Tears.jpg&width=365&product_name=Protective%20Sleeves

LOWER LIMB ULCERS

Venous:

Accounts for 80% of leg ulcers

Due to venous valvular incompetence or occlusion

Managed with compression

Arterial:

Accounts for up to 20% of leg ulcers, often comorbid venous

Due to impaired arterial circulation

Requires revascularization procedure

Diabetic:

Located on feet, most commonly on plantar surface

High risk for infection

Managed with strict off loading

VENOUS LEG ULCERS

NCBI estimates annual cost of $14.9

billion

Affects 3 million Americans, 1% of the

population

Incidence increases to 8% at age 80

Co-morbid arterial disease in 20% of

the cases

VENOUS STASIS DERMATITIS

http://www.skininfection.com/Resources/ImgLib/Dermatitis.html http://hardinmd.lib.uiowa.edu/dermnet/dermatitisstasis6.html

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VENOUS LEG ULCER INTERVENTION

Debridement

Appropriate topical applications

Infection Rx

Compression for acute Rx:

Contraindications and Risks

CHF

Renal failure-fluid overload

PAD-ischemia

Infection

Pain

Pressure ulcer

MANAGE VENOUS HYPERTENSION AND STASIS

Incompetent valves Interventions

Venous intervention

Compression stockings

Circaid garments

http://www.medicographia.com/2011/12/treatment-of-chronic-venous-disease-pathophysiological-underpinnings/ http://www.spectrumhealthcare.net/products/wraps_bandaging

EDEMA RELATED

LYMPHEDEMA SYSTEMIC DISEASE

https://www.google.com/search?q=cardiovascular+edema&source=lnms&tbm=isch&sa=X&sqi=2&ved=0ahUKEwi

wqojLvfbSAhXKRyYKHd5YCjkQ_AUIBigB&biw=1600&bih=808#imgrc=WW55e_LBjnZdoM:&spf=192

BARRIERS TO CHRONIC COMPRESSION

Difficult to self apply

Appears “medical”, not fashionable

Costly

Risks: pain, pressure ulcer, infection

Contraindicated in

Infection

Arterial flow compromise

CHF

DVT

Renal disease

HTN

EDEMA EXERCISES

http://slism.com/wpsystem/wp-content/uploads/easy-edema-treatment-01.gif

ARTERIAL ULCER: ISCHEMIA

20 % of leg ulcers

Most commonly located on toes and lateral

ankle/lower leg

Requires procedure to re-establish flow

Typically painful, either “punched out” appearance

or black dry necrosis

Often present with shiny, taut skin. Dark red or

ruddy with dependency, becomes pale with

elevation. Pulses can be absent, difficult to locate,

however are often present. Don’t be fooled by a

pulse.

http://www.ispub.com/ostia/index.php?xmlFile

Path=journals/ijd/vol1n2/ulcer1.xml

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ARTERIAL WORK-UP AND INTERVENTION

• Palpation and Doppler of pulses

• Vascular studies with ABI and waveforms

• CTA with run-off, MRA, Angiography

• Angioplasty

• Interventional cardiology

• Surgical intervention

• Medication

http://www.cardiogallery.com/CVCTA/Aorta%20Iliofemoral%20Run%20Off%20CTA/Aorta%20Iliofemoral

%20Run%20Off%20CTA.html

ARTERIAL FLOW EXERCISES

http://medical-dictionary.thefreedictionary.com/Buerger-Allen+exercises

Buerger-Allen exercises:

1. Elevate feet on padded chair or board

for 1/2 to 3 minutes.

2. Sit in relaxed position while each foot is

flexed and extended then pronated and

supinated for 3 minutes. The feet should

become entirely pink. If the feet are blue

or painful, elevate them and relax as

necessary.

3. Lie quietly for 5 minutes, keeping legs

warm with a blanket.

From Black and Matassarin-Jacobs, 1997.

LEG ULCERS

VENOUS

Compression

Infection

Debridement

Avoid dependent position

Encourage ambulation

Venous surgical intervention

Venous exercises

ARTERIAL

No compression

Encourage dependent position

Infection

Avoid debridement

Re-establish flow

Buerger-Allen exercises

DIABETIC FOOT ULCERS

US annual cost is > $15 billion

11 million Americans diagnosed

with diabetes, 25 % of these will

develop foot ulcers

1 in 15 will undergo amputation in

their lifetime

50% will survive >3 years

DIABETIC OR NEUROPATHIC ULCERS

Diabetic caused by a combination of hyperglycemia, compromised circulation, decreased sensation, and pressure,

neuropathic caused by decreased sensation and ongoing pressure.

Ulcer typically present on plantar surface of foot, heel or toes. Wound often surrounded by thickened callous

tissue.

Infections are common.

Treatment plan often includes and requires serial debridement, total contact casting, and topical wound therapy.

Requires a collaborative approach, involving diabetes management, nursing care, wound care expertise, often

fittings for orthotics, and at times vascular intervention.

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DIABETIC FOOT ULCERS

Interventions

Blood flow

Infection

Glycemic control

Off load pressure

Debridement

Risks

Fall risk

Renal impairment

Hypoglycemia

Bleeding

Pain

Infection

INFORMED BY THE STATS: DM

ADA estimates annual US cost of DM in 2012 as $245 billion

Number of DM diagnosis is rising

1985: 30 million

2000: 177 million

2010: 285 million

Projected in 2030 at 360 million

Stevens, 2015

INFORMED BY THE STATS: DFU

NIH reported in 2015: lifetime risk of DFU for DM is 15 %

Estimated that approx 20% of acute admissions in diabetic population are for the treatment of DFU

Risks associated with DFU include infection, gangrene, amputation, death

Approximated 50-70% of amputations performed are due to DFU

Worldwide: One amputation is performed every 30 seconds for DFU

Stevens, 2015

OFF-LOADING

Temporary off loading shoe

Diabetic shoe insert and shoe

NWB

http://www.veindirectory.org/magazine/article/techniques-

technology/options-for-non-venous-wounds-diabetic-foot-ulcers

DFU CARE

The Facts:

DM pathophysiology leads to high risk for DFU

DFU rates of infection, amputation, mortality and recurrence are dangerously high

Population of DM is increasing

Aging population is increasing

Prevention does decrease DFU rates

Comprehensive treatment plan to

address:

Infection: potent well absorbed

antibioitics, consider ID referral, podiatry/surgical referral, HBOT. Elderly: high risk for Cdiff, nephrotoxicity.

PAD: Consider cardiology and/or vascular referral.

Neuropathy/arthropathy: total contact casting initially, referral to orthotist. Elderly: high risk for falls and injury.

Glycemic control: collaboration with PCP/endocrinology. Elderly: high risk of hypoglycemia.

PRESSURE ULCERS

AHRQ estimates 2.5 million pressure ulcers yearly

US cost: $9-11.6 billion annually

Individual cost $20,900-151,700 per pressure ulcer

CMS reports each ulcer added $43,180 during hospital stay

More US lawsuits for pressure ulcers than falls or emotional distress, and second only to wrongful death suits

60,000 die annually in the US from pressure ulcers

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PRESSURE ULCERS

RISK ASSESSMENT

Braden Scale:

Immobility

Nutrition

Moisture

Activity

Sensory Deficit

Friction and Sheer

INTERVENTION

PT, frequent repositioning, off loading cushions and

mattresses

Feeding assist, Supplements, L-arginine, TPN

Low air loss mattress, frequent incontinence care, barrier

creams

PT, assistive devices, assistance

Protective splinting, frequent repositioning, off loading

PT for transfer and positioning recommendations, lift

sheets, lower HOB less than 30 degrees if tolerated

TREATMENT PLAN FOR PU’S

Off-loading is crucial

Debridement of necrotic tissue

Pulse lavage: CPI

PT/OT modalities-Estim, PSWD, US

Management of underlying disease process

Thoughtful selection of wound care products

NPWT

Nutritional support

Surgical referral

hamill-law.com

PRESSURE ULCER STAGES

DEEP TISSUE INJURY

UNSTAGEABLE HEEL WOUND

http://www.endocrinetoday.com/view.aspx?rid=33061

“TIME WOUNDS ALL HEELS.”

JOHN LENNON

http://reference.medscape.com/features/slideshow/pressure-ulcer-causes

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OFF-LOADING: A COLLABORATION WITH NURSING, ORTHOTIST, AND

PHYSICAL/OCCUPATIONAL THERAPY

Foot ulcers

Waffle boots

Off loading shoe

Custom orthotics

Total contact casting

CROW boot

Crutches

Non-weight bearing status

Wheelchair

Trunk & Other Body Surfaces

Air mattress

Specialty seated cushions

Custom orthotic splints and devices

Floating body part on pillow

HOW TO DETERMINE…WHAT ARE YOU LOOKING AT?

Caused by ischemia due to compression of tissue between a surface and bony prominence

Located over bony prominence, or area of tissue against external source, i.e. tubing

Stage 1-4, un-stageable, or deep tissue injury

Healed by combination of local wound care and pressure reduction

May be partial or full thickness

Caused by inflammation due to contact with moisture, especially when compounded by chemical irritant and/or altered pH

Located where the skin is exposed to moisture: intertriginous folds, perineum, peri anal, peri ostomy and peri wound

Typical moisture sources include urine, fecal matter, wound exudate, and/or perspiration

Partial thickness: epidermal and dermal tissue loss

Pressure Wounds

MASD: Moisture Associated Skin Damage

PREVENTION AND TREATMENT OF MASD/IAD

Structured skin regimen

Gentle cleansing & moisturizing with a product pH that matches skin pH, use a moistened disposable soft cloth versus hospital washcloth

Application of skin protectant or moisture barrier product, typically petroleum for urine and zinc for fecal

Increase frequency of incontinence brief changes

Off-load pressure: reduce risk of pressure ulcer

Avoid friction and shearing

Treat candidiasis, as needed, with antifungal

Treat cutaneous infections promptly

Gray, Mikel (2007)

SURGICAL WOUNDS

Infection

Edema management

Glycemic control

Mechanical forces and tension

http://m3.i.pbase.com/o6/12/421212/1/101374523.kIMZ12if.wrecked_foot_vacuum_dressin.jpg

ATYPICAL WOUNDS

Biopsy unusual wounds or duration > 6 months without improvement

Malignancies

Bullae/pemphigus disorders

Pyoderma gangrenosum

Viral lesions

Vasculitic lesions

Necrobiosis lipoidica diabeticorum

IDENTIFYING ATYPICAL WOUNDS

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PEARLS IN ELDERLY WOUND CARE

Malodor may be treated with Flagyl 250-500 mg topical to wound bed with dressing changes and/or charcoal wound dressing

Pseudomonas is not a common cause of systemic illness, more often colonized, best treated topically with acetic acid, 0.25 to 3% and avoiding moisture

Regional ID update: corynebacterium striatum often culprit in osteomyelitis, have to ask for sensitivities

Medical device is common culprit in pressure injury, pad well

Collaboration is key, as this age group accesses care in multiple settings with multiple disciplines

History taking and plan of care development requires investigative work

Apply viscopaste without Coban to minimize risk, padding can minimize discomfort and pressure risk

Telfa makes a soupy mess

Bactrim is high risk for DM, elderly and renal dx

Off loading can be a dangerous fall risk

Tight glycemic control is high risk for hypoglycemic event, loosen it up a little

Protein, caloric, and L-arginine supplement for wound healing

Zinc supplement with caution

IN SUMMARY:

Chronological and photoaging structural and functional skin changes increase risk of and delay healing of wounds

Systemic illness more commonly found in elders increase risk of and delay healing of wounds

Medications and treatments of illnesses in elders increase risk of and delay healing of wounds

Socioeconomic factors of an increasing aging population who live longer with chronic illness have increasing rates of poverty and decreasing funds for use in the treatment of wounds

Fear of loss of independence is a barrier to seeking care

Safety risks and treatment side effects unique to elders limit treatment options in would healing

Developing plan of care for prevention and treatment of wounds in the elder population will prevent wound care development and minimize wound therapy adverse effects

REFERENCES

Cubanski, J., Casillas, G., Damico, A “Poverty Among Seniors: An Updated Analysis of National and State Level Poverty Rates Under the Official and Supplemental Poverty Measures” Jun 10, 2015. http://kff.org/medicare/issue-brief/poverty-among-seniors-an-updated-analysis-of-national-and-state-level-poverty-rates-under-the-official-and-supplemental-poverty-measures/

Fore, Jane MD, A Review of Skin and the Effects of Aging on Skin Structure and Function, Ostomy Wound Management, vol 52, Issue 9, Sept 2006. http://www.o-wm.com/content/a-review-skin-and-effects-aging-skin-structure-and-function

Gray, Mikel (2007) Incontinence Related Skin Damage: Essential Knowledge. Ostomy Wound Management 2007; 53(12):28-32.

LeBlanc, Kimberly, Baranoski, Sharon, Skin Tears: Finally Recognized, Advances in Skin & Wound Care: The International Journal for Prevention and Healing, Vol 30, No. 2 Feb 2017.

Levine, JM, The Effect of Oral Medication on Wound Healing, Advances in Skin & Wound Care: The International Journal for Prevention and Healing, Vol 30 No 3, March 2017.

MacNeal, Robert J., MD, Effects of Aging on the Skin, http://www.merckmanuals.com/home/skin-disorders/biology-of-the-skin/effects-of-aging-on-the-skin

Park-Lee, Eunice, PhD and Caffrey, Christine, PhD of US Dept of HHS CDC National Center for Health Statistics, Pressure Ulcers Among Nursing Home Residents: United States, 2004, NCHS Data Brief, No. 14, Feb 2009, https://www.cdc.gov/nchs/data/databriefs/db14.pdf

Posthauer, ME, Banks, M, Dorner, B, Schols, J, (2015) 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, Advances in Skin and Wound Care, April 2015.

Stevens, Phil, Med CPO, FAAOP (2015) The Cost of Diabetic Foot Ulcers, The O&P EDGE, Aug 2015, http://www.oandp.com/articles/2015-08_02.asp

West, Loraine A.; Cole, Samantha; Goodkind, Daniel; He, Wan. “65+ in the United States: 2010,” U.S. Census Bureau, P23-212, Government Printing Office, Washington, DC, 2014. https://www.census.gov/content/dam/Census/library/publications/2014/demo/p23-212.pdf

GERIATRIC RESOURCES

Agency for Healthcare Research and Quality http://www.ahrq.gov

Administration on Aging http://www.aoa.gov

National Institute on Aging http://www.nia.nih.gov

Non-Profit Organizations Health and Age Foundation http://www.healthandage.org

American Federation of Aging Research http://www.afar.org

Alliance for Aging Research http://www.agingresearch.org

National Council on Aging http://www.ncoa.org

The National Gerontological Nursing Association http://www.ngna.org

The National Conference of Gerontological Nurse Practitioners http://www.ncgnp.org/

The American Geriatrics Society http://www.americangeriatrics.org/

NICHE: Nurses Improving Care for Healthsystem Elders http://www.nicheprogram.org/