Introduction
In long-term care, chronic ulcers involve issues that are both labor-intensive and costly. When dressings are changed two to three times a day, labor and wound care product expenses can be significant. Chronic ulcers are often used as an indicator of health care quality and are frequently cited in litigation against long-term care and home health care settings.¹ Health care providers may not fully manage the underlying cause of a chronic ulcer, thus limiting a wound’s healing potential. The vast number of wound care products available for use can also be confusing for health care providers. Providers should also realize that despite a comprehensive treatment regimen, some wounds simply will not heal.

Principles of wound healing and factors that delay wound healing are listed in Tables I and II. One must fully understand these concepts in determining an appropriate diagnosis and before a practical wound care regimen can be executed. Since prevention is the best treatment for all of these ulcers, it is also important to recognize those patients who are at greatest risk for developing chronic wounds. Early intervention minimizes cost and improves patient comfort.

Ischemic Ulcers
Ischemic ulcers are chronic wounds caused by vascular insufficiency or trauma. They are associated with other medical conditions such as atherosclerosis obliterans, inflammatory diseases, and vasospastic conditions. The incidence of ischemic ulcers is nearly 20% in people over 65 years of age.² The prevalence of ischemic ulcers is about 18% in men over age 55 and in women over age 60. The male-to-female ratio is 2:1.² Most elderly residents are asymptomatic. About 70% of a vessel’s lumen must be occluded before this situation can be clinically recognized.²

Ischemic ulcers occur distally, have discrete borders, and are usually painful. The skin is thin, shiny, and dry. Dependent rubor is present, and elevation pallor occurs within seconds after elevating the foot.³ The wound base is pale, and distal pulses are not palpable (the posterior tibial pulse is always present, but the dorsalis pedis pulse is normally absent in about 5% of healthy individuals).² Sedentary residents who do not walk to the point of claudication may initially present with foot pain at rest or with gangrene. Rest pain is relieved with dependency as gravity increases arterial flow into the ischemic foot. Resting foot pain is an ominous indicator that blood flow has been reduced to less than 10% of normal.²

Assessment
A lower extremity arterial evaluation is indicated if there is a high clinical index of suspicion for ischemic disease. Although vascular studies in a laboratory setting are ideal, these may not be available or readily obtained. A practical and cost-effective approach is the ankle-brachial index (ABI), which can be performed at the bedside. This is achieved by using a blood pressure cuff and hand-held Doppler ultrasound exam. Systolic blood pressures are monitored at the ankle and brachial arteries with a Doppler probe. The ankle systolic blood pressure is divided by the brachial artery systolic blood pressure to produce a ratio:3

A normal ABI is greater than 0.9. An ABI of less than 0.9 is abnormal and most likely represents occlusive disease. An ABI less than 0.7 suggests that peripheral arterial disease is contributing to nonhealing. An ABI of less than 0.3 can result in rest pain or tissue damage.¹ Many elderly residents with diabetes, however, have noncompressible vessels, which render an ABI inaccurate. Transcutaneous oxygen levels may be more reliable when ABI results are not consistent with clinical features.¹ A more detailed evaluation also includes radiographs to screen for possible osteomyelitis. Angiography may be warranted to further evaluate the degree of arterial involvement and to help guide further appropriate care, especially if surgery is being considered.

Management
Smoking cessation is paramount in managing ischemic wounds. Nicotine is a potent vasoconstrictor that not only promotes atherosclerosis but further impedes blood flow to an ischemic limb. Diabetes, hypertension, and pain need to be optimally controlled. The ischemic limb should be kept warm and protected to prevent further insult. Keeping ischemic areas warm promotes vasodilatation that improves arterial blood flow. Vascular boots are often used for this purpose, as based on clinical observation. Lamb’s wool can be woven between the toes to keep the interdigital areas padded and to prevent ulcer formation. Increasing perfusion can also be accomplished by utilizing compression boot therapy or intermittent pneumatic pumps. Compression boot therapy is noninvasive and can be done in an outpatient setting; this can potentially minimize hospitalizations and the need for invasive procedures.⁴ Evidence suggests that improving perfusion in an ischemic limb will enhance arterial flow and promote the development of collateral circulation.⁴

Physical activity helps maintain peripheral perfusion, and any form of dynamic leg exercise is effective.⁵ This is especially important for elderly patients who can no longer walk as a form of exercise. Introducing and gradually increasing the pumping action of the lower leg mimics walking. This can be achieved through pedaling exercises or dorsiflex devices. Involving the expertise of a physical therapist as part of a comprehensive treatment plan is invaluable.

Wet-to-moist dressings should be avoided when treating ischemic ulcers. Turning dry gangrene into wet gangrene increases the likelihood of infection, so it is important to keep these ulcers dry. This is achieved by keeping them covered with dry gauze dressings. Utilizing the drying properties of cadexomer iodine gel around these ulcers accomplishes this same purpose. The iodine helps decrease the bioburden as it gently debrides devitalized material. Silver sulfadiazine can also be used. Care needs to be taken when sharply debriding the eschar so no further damage is done to surrounding tissues. Surgical revascularization is required for those patients who have failed maximal medical management and have gone on to develop symptoms of worsening limb-threatening ischemia. When compared to amputation, revascularization is less expensive, and long-term survival is improved.⁶ Advancing age and worsening vascular disease increase the risk of amputation.⁷ Despite comprehensive medical therapy and invasive limb salvaging techniques, lower extremity amputation may be necessary to definitively treat ischemic ulcers.

Pressure Ulcers
Pressure ulcers are chronic wounds that result from increased pressure or shearing force over a susceptible area, usually a bony prominence. Not only is the overlying skin damaged, but the unresolved pressure also damages underlying tissue. The federal Agency for Healthcare Research and Quality (AHRQ) defines a pressure ulcer as an injury to skin and muscle that is caused by constant pressure that develops when the skin and underlying structures are deprived of oxygen and other nutrients necessary for cell growth and proliferation.^8,9 The incidence of pressure ulcers is estimated to be about 23% of nursing home residents. Pressure ulcer prevalence is between 5-10% of hospitalized patients and about 15% of nursing home residents.⁹ It is also estimated that pressure ulcers affect between 1.5 to 3 million Americans and account for $5 billion in health care expenditures.⁹ Those at increased risk include the elderly, residents with incontinence, bed- or wheelchair-bound residents, or those recovering from spinal cord injuries.

Assessment
Pressure ulcers develop when skin pressure exceeds the pressure that occludes capillary flow. Pressure ulcer development occurs in four stages:
• Stage I: Hyperemia develops after pressure has been applied over an area for up to 30 minutes. The redness generally resolves within 1 hour after the pressure is relieved.
• Stage II: Ischemia results after 2-6 hours of continuous pressure. It may take 36 hours or more to resolve after the pressure is relieved.
• Stage III: Necrosis develops after 6 hours of continuous pressure. Damage resolves on an individual basis.
• Stage IV: Ulceration occurs within 2 weeks after the necrosis has developed. This creates a high potential for infection. The ulcers resolve on an individual basis.^1,8

The Norton and Braden risk assessment surveys are frequently used to identify high-risk patients. Although the Braden Scale has shown a high level of accuracy for predicting ulcer formation,⁹ the predictive value for ulcer formation in long-term care has been questioned.¹ For each high-risk resident, an estimated 29-79 minutes of nursing time per day is needed to provide adequate preventive care.¹

Management
Prompt treatment of pressure ulcers is crucial since untreated ulcers will worsen, which may lead to cellulitis, chronic infection, or osteomyelitis.¹⁰ Effective pressure ulcer management includes pressure relief, debridement, cleansing, and appropriate dressings. Sharp debridement utilizes the use of a scalpel and scissors to rapidly remove devitalized material from a wound. Mechanical debridement utilizes the use of moistened wound packings to remove wound debris. Enzymatic debridement utilizes topical agents to remove devitalized tissue. Autolytic debridement uses occlusive or nonocclusive dressings over a wound to allow the devitalized material to self-digest.^10,11 Autolytic debridement is not indicated for infected wounds. Wounds should be cleansed with saline with each dressing change. Povidine-iodine, iodophor, sodium hypochlorite solution (Dakin’s solution), hydrogen peroxide, and acetic acid should be avoided as cleansing agents since they are cytotoxic to granulating tissue.^1,10 A summary of wound care products that are used to treat pressure ulcers is listed in Table III. Vacuum-assisted closure (VAC) has been designed to promote granulation tissue for faster healing of various types of ulcers. By applying negative pressure uniformly over a wound, the arterioles dilate to increase blood supply. Wound drainage and debris are drawn away, and oxygen and growth factors are drawn to the wound bed. Since wound VAC is portable and not labor-intensive, it is a good treatment option in long-term care to enhance chronic wound healing.¹²

Routine culturing of pressure ulcers (in the absence of clinical signs of infection) is of questionable value,9 since all of these ulcers are colonized with a plethora of different organisms. Wounds colonized with Pseudomonas aeruginosa have distinct green-tinged drainage and a sweet odor. Short-term use of a weakened acetic acid solution (0.25%) in wet-to-moist dressings is a cost-effective and efficient way of controlling this organism.¹³

Table IV summarizes the different types of support surfaces that are generally used in managing pressure ulcers. Static mattresses are appropriate for patients who can change positions on their own without bearing weight over an ulcer. Dynamic mattresses are used for patients who cannot change position on their own without putting pressure over an ulcer, or for those whose ulcer is not healing. Pressure reduction can also be achieved by using turning schedules, passive repositioning, and pillows.¹³ One pressure reduction strategy is keeping the head of the bed elevated no more than 30 degrees in order to minimize shearing force.¹¹ Gel or high-density foam pads help reduce pressure, but no cushion relieves pressure entirely. Inflatable rings should be avoided as they create more pressure around the opening of the ring.

Nutritional status also needs to be addressed, as good nutrition is essential for wound healing. Total caloric intake should be at least 30-35 calories/kg/day, and protein intake should be 1.5 g/kg/day. Multivitamin supplementation may be beneficial and is practically safe for every patient.¹³

Venous Ulcers
Venous ulcers are a major cause of morbidity in the elderly, in addition to decreasing mobility and quality of life.¹⁴ Residents in long-term care face these same challenges. It is estimated that up to 4% of the population over age 65 develop venous ulcers.¹⁵ In the United States, it is estimated that 2.5 million people have or will develop venous ulcers, costing more than $4 billion to treat.¹ Edema, secondary to superficial venous incompetence, perforator incompetence, or postphlebitic syndrome, is generally the cause. Pressure ulcers typically involve the gaiter area (the region located circumferentially from the mid-calf to just below the medial and lateral malleoli). They have irregular borders and may have satellite lesions. The wound base may appear red and beefy or pale pink (due to edematous changes). These wounds are generally pain-free unless infected, which often exacerbates lower leg edema. Most residents note significant exudate from these wounds. The presentation of a venous ulcer is different than the typical decubitus ulcer usually seen in long-term care. Families or the resident describe a recurrent pattern of breakdown and then healing with appropriate care.¹⁶

Assessment
Physical findings are often diagnostic when examining venous ulcers. The provider should document the amount of swelling within the leg and around the wound. This can be done in a subjective fashion, or it can be quantified by measuring the circumference of the involved extremity. A comprehensive evaluation should document the depth, shape, and size of the ulcer. The periulcer area should be inspected for venous stasis changes and maceration. Frequently, chronic ulcers are of mixed etiology, with an ischemic or pressure component coexisting with a venous component. The exam should also evaluate the cardiac, hepatic, and pulmonary systems. An ischemic process needs to be excluded.¹

Providers must diagnose the etiology of edema and correct those conditions that can be reversed. Although cellulitis can worsen edema, it is often diagnosed without evidence of infection.17 Providers should initiate antibiotics when there is clear evidence of local edema, erythema, and warmth. Etiologies for common sources of edema and diagnostic testing are listed in Table V. Diagnostic testing in long-term care must be balanced with potential outcomes.

Management
Healthcare providers should employ a threefold approach when treating venous ulcers. First, adequate compression should be initiated to control edema by using mechanical (and occasionally) pharmacologic methods.¹ Providing adequate edema control in long-term care is limited by cognitive decline and time. Using standard compression alone, one could expect to heal 50-60 % of these wounds. If they have been present for more than a year, however, only 20% go on to heal.¹⁸ The recurrence rate can be as high as 70%. Therefore, compression therapy and education are paramount in preventing recurrence.¹⁸ Secondly, underlying factors causing edema or venous hypertension must be treated. Thirdly, an appropriate wound care regimen needs to be specific to venous ulcers. Specific treatments of underlying illnesses that cause edema are listed in Table V. Diuretics should have a secondary role in venous ulcer management. The amount of periulcer maceration will dictate which wound product is appropriate. An appropriate wound dressing for venous ulcers is one that absorbs exudate and protects fragile skin around the ulcer. Gauze dressings work well on ulcers with mild to moderate amounts of exudate. If the exudate is difficult to contain with this dressing, alginate or foam dressings have better absorptive properties to control excessive drainage. Wounds containing devitalized material should be debrided to improve wound hygiene.

Mechanical methods of reducing edema are safe and effective. Thirty minutes of leg elevation 3-4 times a day can be effective in reducing mild edema. For significant edema, compression wraps are necessary. Single-layer compression wraps are most commonly used in long-term care. The wrap needs to be applied in a figure eight configuration to adequately compress and keep the wrap in place. As the edema shifts, these wraps need to be redone periodically. Low-stretch wraps are an excellent alternative for those patients who cannot tolerate regular wraps or who also suffer from peripheral arterial disease. Multilayer wraps are superior to single-layer wraps.^19,20 Multilayer wraps involve an initial layer to hold the dressing in place, followed by two additional wraps. This system provides better edema control with more uniform pressure. Although it is more time-consuming, it may be more appropriate for residents with chronic, nonhealing ulcers. Compression hose should only be worn once the ulcer has fully healed. If they are used while an ulcer is present, the shearing force associated with donning these stockings will worsen the ulcer.

Surgical options for reducing venous hypertension are effective²¹ but often are not practical in the long-term care setting. Residents and families need to weigh the potential risks and benefits of surgery.

Neuropathic Ulcers
Neuropathic ulcers are often associated with diabetes mellitus. They are generally traumatically induced ulcers that occur in areas affected by peripheral neuropathy—most commonly the feet. They develop over regions of high pressure²² such as the metatarsal heads. These ulcers are generally not painful. Often the resident presents with evidence of skin or bone infections. Fever, chills, and a strong odor are also presenting complaints.²³ Residents with infected neuropathic ulcers have a much higher mortality rate than those whose ulcers are free of infection.²⁴

Assessment
A thorough examination for peripheral neuropathy should include peripheral nerve monofilament testing and a comprehensive vascular examination.²⁵ Diagnostic testing for peripheral neuropathy is rarely needed since a clinical diagnosis can be confirmed by symptoms of paresthesia, neuropathic pain, and numbness (as determined by a positive monofilament test). In select cases, electromyelography may prove beneficial. The provider should probe the ulcer with a sterile instrument to determine the depth and extent of the ulcer. These ulcers are often very deep and invade muscle, tendon, and bone. If exposed bone is soft with sterile probing, underlying osteomyelitis is almost assured,²⁶ requiring further investigation. A sedimentation rate, complete blood count, bone biopsy, radiographs or other imaging studies may be needed to determine the extent of osteomyelitis.²⁷

Management
Adequate offloading is important in treating neuropathic ulcers. While this is ideal, it is not always practical in long-term care. Residents need to wear appropriate footwear or remain nonweightbearing. Even the slightest amount of shearing force over a neuropathic ulcer will inhibit healing. Crutches and wheelchairs may be used, but these can lead to decreased function and muscle weakness. Although the emphasis has been on pressure reduction, there has been some debate over its effectiveness.²⁸

An effective care plan should consider the resident’s cognitive status, functional status, lower extremity strength, and the site of ulceration. It should also ensure a moist wound environment with adequate packing of the ulcer. Saline-moistened half-inch or quarter-inch gauze ribbon is generally used to pack these ulcers and any areas of tunneling. A hydrogel can be added to help maintain wound hydration. If necrotic tissue is present, a topical debriding agent can be used, but this should only be used for a short time to prevent damage to surrounding tissues. Any periulcer callus should be debrided.

Inserts help offload problem areas by directing pressure away from the ulcer and distributing it to the rest of the foot.²⁹ These work best when they are custom-fitted for a foot whose architecture is intact. Wound shoes may be an option for some residents and are designed with a rocker bottom sole to reduce pressure over the metatarsal heads.³⁰ Diabetic walkers are the most extensive way of offloading the foot while maintaining gait. These devices offload pressure from the foot and transmit it to the calf. They can impede a resident’s gait and can be difficult for a resident to apply. For these reasons, custom inserts or wound shoes are preferred for less active residents.

If these ulcers do not heal with conservative measures, residents and families often expect other care options. These options include advanced wound care techniques, continued conservative care, or amputation. In long-term care, each of the above options must be evaluated in the context of quality of life, life expectancy, and personal wishes of the resident and family. Advanced wound care techniques include platelet-derived growth factors (becaplermin gel), collagen-based products, bioengineered skin replacements, hyperbaric oxygen and compression pumps. While becaplermin gel was shown to be effective in treating neuropathic wounds,³¹ the population studied was younger than those who typically reside in a long-term care setting. It can be difficult for older residents to undergo some of the advanced wound care treatments, as they may interfere with quality of life. Providers must realize that if neuropathic ulcers fail to heal after a reasonable trial of comprehensive wound care, long-term healing will most likely not occur. Amputation may be the only reasonable treatment option at this point. Prognosis is poor after amputation³² so the decision to do so must be made with the resident’s and family’s input regarding their goals and expectations.

Conclusion
Chronic wounds are frequently encountered in long-term care settings where elderly residents have co-existing chronic medical conditions. Treating these ulcers are costly and challenging. Given the vast number of wound care products available, it can be difficult to determine which wound product to use for a specific wound. By understanding the basic principles of wound healing and factors that delay healing, a practical and effective wound care regimen can be instituted. By properly diagnosing an ulcer and implementing an appropriate treatment strategy, many of these ulcers can heal.