Peripheral Arterial Disease and Its Consequences: Considerations for Long-Term Care
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Peripheral arterial disease (PAD) in the LTC setting has major consequences in terms of mortality, morbidity, and increased healthcare costs. Complications include pain, chronic skin ulceration, gangrene, amputation, infection, and death. In recent years, medical-legal liability for providers caring for residents with this disease has increased. PAD is complex and involves inflammation and accumulation of lipids in the vascular intima, causing occlusion of blood flow. Chronic occlusive disease causes trophic changes in the extremity that renders skin more fragile and difficult to heal when minor trauma occurs. Noninvasive vascular studies are recommended to establish the diagnosis and quantify amount of occlusion. Management of this disease starts with modification of risk factors. Medications include antiplatelet agents and statins, but their role in healing arterial ulcers is uncertain. Treatment of arterial ulceration consists of wound bed preparation, and chronic skin ulceration related to PAD should be documented in the same manner as pressure ulcers, with care of all chronic wounds in LTC an interdisciplinary function. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[2]:22-26)
Introduction
Peripheral arterial disease (PAD) in the long-term care (LTC) setting has major consequences in terms of morbidity and mortality but is a condition that is often underdiagnosed.1,2 Also known as atherosclerotic peripheral vascular disease, complications can include lower-extremity weakness with impaired functional status, increased rate of functional decline, pain, chronic skin ulceration, gangrene, amputation, infection, and death.3-5 PAD results not only in morbidity and mortality, but significantly increases the use of healthcare resources and costs.6 The American Heart Association estimates that as many as 8 million Americans have PAD, and the prevalence based on ankle-brachial blood pressure ratios is approximately 10-20% of community-dwelling individuals age 65 years and older.7,8 Diagnosis is sometimes challenging, and classification of skin ulcers resulting from occlusive arterial disease can be confusing in light of current staging systems and requirements of the Minimum Data Set (MDS). In addition, there is the issue of medical-legal liability when a limb is lost or sepsis is incurred as a result of gangrene or infection.9 This article will provide a basic guide to atherosclerotic occlusive disease of the lower extremity, reviewing diagnostic modalities and highlighting specific challenges in management.
Arterial disease occurs in the setting of risk factors that include diabetes mellitus, hypertension, hypercholesterolemia, and smoking. Recently established biochemical risk factors include elevated C-reactive protein and elevated homocysteine levels. Persons who smoke or have diabetes have a higher rate of limb amputation and increased difficulties with wound healing. The old medical term atherosclerosis obliterans is applicable because this disease is generally present elsewhere in the body. Atherosclerosis of arteries of the lower extremity is frequently observed in patients with a history of stroke, multi-infarct dementia, carotid stenosis, coronary artery disease, renovascular hypertensive disease, and thoracic aortic aneurism.10 Risk factor intervention with cessation of smoking and control of blood pressure and diabetes is a major management strategy, but many LTC patients already have advanced, irreversible disease. However, this should not preclude attempts at controlling risk factors and providing suitable pharmacotherapy.
Pathogenesis of Atherosclerotic Disease and Associated Dermal Changes
Atherosclerosis is a disease of vascular endothelium of large- and medium-sized arteries, and is complex and multifactorial in its genesis.
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