What is skin breakdown in the elderly? Causes, Symptoms, and Prevention

According to Medline, over 90% of older people have some form of skin disorder, making it a critical aspect of senior health. Understanding what is skin breakdown in the elderly is crucial for caregivers and family members, as it involves the deterioration of skin integrity and can lead to serious health complications like pressure ulcers and infection.

Quick Summary

Skin breakdown in the elderly is the loss of skin integrity due to factors such as prolonged pressure, friction, and moisture. It presents with symptoms like redness, swelling, and open sores, and requires vigilant care and preventative measures to manage effectively and avoid severe complications.

Key Points

• Definition: Skin breakdown is the loss of skin integrity, common in older adults due to thinner, more fragile skin.

• Common Causes: Primary causes include prolonged pressure (leading to pressure ulcers), friction, shear, and excessive moisture from incontinence.

• Risk Factors: Increased risk is linked to limited mobility, poor nutrition, dehydration, certain medications, and chronic illnesses like diabetes.

• Staging: Pressure injuries are staged from 1 (non-blanchable redness) to 4 (deep tissue loss exposing bone or muscle), with unstageable injuries being covered by dead tissue.

• Prevention Strategies: Key preventative measures include frequent repositioning, managing moisture, ensuring proper nutrition, and using pressure-relieving surfaces.

• Treatment Approach: Treatment ranges from home care for minor issues to medical intervention for advanced stages, focusing on reducing pressure, wound cleansing, and proper dressings.

• Early Detection: Regular, careful skin assessments are crucial for identifying signs of skin breakdown early, making treatment significantly easier and more effective.

What Exactly is Skin Breakdown in the Elderly?

Skin breakdown refers to the loss of skin integrity, leading to tissue damage. In older adults, this is a significant concern because aging naturally makes skin thinner, more fragile, and less elastic. This reduced resilience, combined with other age-related factors, makes the elderly particularly vulnerable to skin injuries, which can take much longer to heal.

The most common types of skin breakdown seen in older adults include:

• Pressure Injuries (Bedsores or Pressure Ulcers): These form from prolonged, unrelieved pressure on the skin, especially over bony areas like the tailbone, hips, and heels, which restricts blood flow.
• Skin Tears: This type of breakdown involves the separation of the top layers of skin, often caused by friction or shear, such as when being moved in bed or bumping into furniture.
• Moisture-Associated Skin Damage (MASD): Occurs from extended exposure to moisture, such as urine or sweat, which can soften the skin and make it more susceptible to damage.

Key Causes and Risk Factors

Multiple factors can contribute to the development of skin breakdown in seniors. These influences are often interconnected, increasing the overall risk.

Age-Related Factors

• Thinner, Less Elastic Skin: Reduced collagen and fat layers make skin more susceptible to trauma and pressure.
• Slower Healing: The skin's ability to repair itself diminishes with age, slowing wound healing significantly.
• Impaired Sensory Perception: Neurological changes or conditions like diabetic neuropathy can reduce the ability to feel pain or discomfort, so an individual may not know they need to change position.

Mobility and Physical Factors

• Limited Mobility or Immobility: Being bedridden or using a wheelchair for long periods is a primary risk factor for pressure injuries.
• Incontinence: Exposure to moisture from urine or feces is a significant cause of MASD and a precursor to pressure injuries.
• Nutritional Deficiencies: Inadequate protein, vitamins, and fluids compromise skin health and slow healing.

Environmental and Medical Factors

• Medications: Certain drugs, like corticosteroids, can thin the skin and increase fragility.
• Friction and Shear: The rubbing of skin against surfaces, especially during repositioning, can cause injury.
• Chronic Conditions: Diseases such as diabetes and vascular issues affect blood flow and impair skin repair.

Recognizing the Symptoms: A Stage-by-Stage Guide

Identifying skin breakdown early is critical for effective treatment. The most common type, pressure injuries, progresses through several stages.

Stage of Skin Breakdown	Appearance and Characteristics	Key Signs to Watch For
Stage 1	Intact skin with localized, non-blanchable redness over a bony area. For darker skin, it may appear as persistent red, blue, or purple hues.	Discoloration that does not turn white when pressed, along with possible changes in temperature, texture, or sensation.
Stage 2	Partial-thickness skin loss involving the epidermis and dermis. Presents as a shallow open ulcer with a red or pink wound bed, or a ruptured or intact blister.	Open sore or blister, pain, and possible swelling around the wound.
Stage 3	Full-thickness skin loss extending into the subcutaneous tissue (fat layer). May look like a deep crater.	Deeper ulcer, visible fat tissue, possible undermining (tunneling) beneath the skin.
Stage 4	Full-thickness skin and tissue loss with exposed bone, tendon, or muscle.	Extremely deep ulcer, visible bone or muscle, presence of slough (yellow tissue) or eschar (black dead tissue).
Unstageable	Full-thickness tissue loss obscured by slough or eschar. The true depth cannot be determined until the wound bed is cleared.	Wound covered by thick yellow or black tissue, making assessment difficult.
Deep Tissue Injury (DTI)	Area of purple or maroon discolored intact skin. Caused by underlying soft tissue damage from pressure and/or shear.	Discolored area that is persistent and non-blanchable. May feel firm, boggy, or warmer/cooler than surrounding skin.

Prevention is the Best Medicine

Preventing skin breakdown is far easier and more cost-effective than treating it. Proactive measures are essential for any caregiver.

• Regular Repositioning: For individuals with limited mobility, shifting their position every two hours (or more frequently for high-risk individuals) helps relieve pressure on vulnerable areas.
• Manage Moisture and Incontinence: Use premium, highly absorbent incontinence products and change them frequently. Clean and dry the skin thoroughly, and consider using moisture barrier creams.
• Ensure Proper Nutrition and Hydration: A diet rich in protein, vitamins (especially C and A), zinc, and healthy fats helps maintain skin integrity and promotes healing. Adequate fluid intake prevents dehydration, which makes skin more fragile.
• Use Pressure-Relieving Surfaces: Specialized mattresses, cushions, and pads can help distribute pressure and protect bony prominences.
• Gentle Skin Care: Use warm (not hot) water and pH-balanced, gentle cleansers during bathing. Pat the skin dry instead of rubbing.
• Regular Skin Assessments: Conduct daily skin checks, paying close attention to bony areas like the tailbone, hips, and heels, to catch any issues in their earliest stages.
• Handle with Care: Avoid dragging or pulling the skin during transfers. Lift gently to prevent friction and shear injuries.

Treatment and Management

Treatment depends on the stage and severity of the breakdown. Minor issues can often be managed at home, but advanced stages require professional medical care.

1. Reduce Pressure: The first and most crucial step is to eliminate the pressure that caused the injury. Use supportive surfaces and ensure frequent repositioning.
2. Cleanse the Wound: Open sores should be cleaned with a saline solution each time the dressing is changed.
3. Apply Proper Dressings: A moist wound environment promotes healing and protects against infection. Advanced wound dressings are available, and a soft silicone wound contact layer is often used for skin tears.
4. Debridement: For more severe wounds with dead tissue (eschar), a healthcare provider may need to perform debridement, which involves removing the damaged tissue.
5. Address Underlying Issues: Treating the root cause, such as managing incontinence or improving nutrition, is vital for long-term healing and prevention.
6. Seek Medical Help: Any signs of advanced breakdown, deep wounds, or infection (like increasing pain, drainage, or odor) require immediate medical attention. In severe cases, a hospital stay or surgery may be necessary.

Conclusion

Understanding what is skin breakdown in the elderly is a fundamental part of providing comprehensive senior care. By recognizing the risk factors, performing regular skin checks, and implementing proactive preventative measures, caregivers can significantly reduce the incidence of this painful and dangerous condition. Prompt and appropriate treatment is key to managing any breakdown that does occur, helping to prevent serious complications such as infection and to preserve the elder's overall health and quality of life. For comprehensive resources on wound care, caregivers can consult authoritative sources like the National Pressure Injury Advisory Panel (NPIAP).

Frequently Asked Questions

What is the very first sign of skin breakdown in an elderly person?

The first sign of skin breakdown is often a localized area of persistent redness on intact skin, especially over bony prominences like the tailbone or hips, that does not turn white when pressed. For individuals with darker skin tones, the area may appear a different color, such as blue or purple.

How can I prevent skin breakdown caused by incontinence?

To prevent skin breakdown from incontinence, use highly absorbent products that wick moisture away from the skin. Change soiled products promptly, and thoroughly clean and pat the skin dry during changes. Applying a moisture-barrier cream can also create a protective layer.

Which areas of the body are most susceptible to skin breakdown in seniors?

Areas of the body with bony prominences are most susceptible, including the tailbone, hips, heels, elbows, ankles, and shoulder blades. These areas endure significant pressure when a person is seated or lying down for extended periods.

Can diet affect skin health and the risk of breakdown?

Yes, a healthy diet is critical for maintaining skin health and preventing breakdown. Adequate intake of protein, fluids, vitamins A and C, and essential fatty acids helps keep the skin resilient and supports the healing process.

How often should I reposition a bedridden elderly person to prevent pressure ulcers?

To prevent pressure ulcers, a bedridden elderly person should generally be repositioned every two hours. For high-risk individuals, more frequent repositioning may be necessary. Use supportive surfaces and devices to aid in pressure relief.

What is the difference between friction and shear in relation to skin breakdown?

Friction occurs when the skin rubs against a surface, like bedding, causing surface damage. Shear happens when two surfaces move in opposite directions, and the skin stays in place while underlying tissue shifts, which can damage blood vessels.

When should I seek medical help for skin breakdown?

You should seek medical help if the skin breakdown progresses beyond minor redness. Signs that require professional attention include open sores, blisters, increasing pain, visible drainage, signs of infection (foul odor, warmth, swelling), or if the wound is covered by dead black or yellow tissue.