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Chronic Wound Pain in Older Adults - HealthPlexus.net

Chronic Wound Pain in Older Adults - HealthPlexus.net

Chronic Wound Pain in Older Adults -

abstract PAIN Chronic Wound Pain in Older Adults Madhuri Reddy, MD, MSc, FRCPC, Assistant Professor, University of Toronto, Sunnybrook and Women's College Hospital,Toronto, ON. Chronic wound pain adversely affects quality of life and causes functional impairment in the older adult. As the population ages and the prevalence of chronic illness increases, an explosion in the number of chronic wounds is expected in both long-term care and community care. Chronic wounds have a myriad of causes and complications,and care can be complex.The most common types of chronic wounds include venous stasis ulcers,diabetic ulcers and pressure ulcers. There is a paucity of clinical trials of chronic wound pain management in the older patient. In the absence of an adequate evidence base, we present a comprehensive clinical approach to chronic wound pain management. Key words: chronic wounds, pain, venous stasis, diabetes, pressure. Chronic wounds in the older adult adversely affect mortality and morbidity and have an enormous financial impact on the individual and society. The most common types of chronic wounds include venous stasis ulcers, diabetic ulcers and pressure ulcers. The Wound Management Paradigm is a basis for the management of chronic wounds and has been used extensively by wound care specialists. 1 It consists of three major principles: 1) treating the underlying cause of the wound; 2) addressing patient-centred concerns; and 3) providing local wound care. The management of chronic wound pain can be integrated into these pillars of chronic wound management (Figure). General Approach to Chronic Wound Pain Treat the Cause Treating the cause of chronic wound pain may involve removing the source of the noxious stimulus. This will be reviewed in more detail when the types of chronic wounds are discussed more specifically. Patient-centred Concerns Pain in chronic wounds is a major concern for patients and health care providers and numerous studies have shown that chronic wounds adversely affect quality of life. 2 Patients view pain as the worst aspect of their chronic wound, and they rank pain control as more important than wound healing. 3 Pain has been shown to be a primary reason for why patients who seek wound care fail to attend clinic appointments. 4 The patient and health care provider should work together to identify common goals of wound care, and their roles and responsibilities in the therapeutic relationship should be defined. In some chronic wounds it may not be reasonable to set healing as a goal, such as when some patients with pressure ulcers have multiple comorbidities and may be at the end of life. Instead, the focus may be on pain control, management of exudate and odour and improved quality of life. Local Wound Care Dressing removal is usually cited by both patients and health care professionals as the time when the most pain occurs. 5,6 Fear of pain with dressing removal can be significant, so discussion with the patient about their possible concerns prior to the event is crucial. Pain at dressing change can be minimized by adopting strategies to reduce pain and trauma (e.g., soaking old dressings with saline or even 4% topical lidocaine prior to removal), and by choosing dressings with pain-reducing characteristics (e.g., using non-adhesive or using atraumatic dressing products such as soft silicones, hydrogels and alginates). 7 Dried out dressings and adherent products are most likely to cause pain and trauma at dressing changes, with gauze removal being the most common cause of this pain. Many dressings and topical treatments contain allergens that can result in inflammation, and resultant discomfort or pain. Products with high sensitization potential (neomycin, bacitracin, lanolin, perfumes) should be avoided in settings such as leg ulcers. 8 Debridement Wound debridement can be achieved through autolytic, enzymatic, mechanical and/or sharp surgical means. 9 The risks and benefits of the type of debridement in each patient should be weighed carefully. Autolytic debriding agents, particularly hydrogels or hydrocolloids, may help 14 GERIATRICS & AGING • March 2004 • Volume 7, Number 3

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