Applying Frailty Syndrome to the Skin: A Review and Guide for Prevention and Management

Enhancing skin health and preventing skin barrier function damage are integral parts of nursing practice across the continuum of care,1 and skin integrity is an important quality indicator. During the life span, there are periods (such as older age) in which the skin is more vulnerable, rendering individuals more susceptible to skin injury (skin frailty).2 The International Skin Tear Advisory Panel (ISTAP), in its previous decade of work, has identified key knowledge gaps in the prevention and management of skin problems and recognized a need for guidance focused on the shared risk factors and preventive strategies for common skin conditions faced by individuals with vulnerable skin: skin tears, pressure injuries/ulcers, moisture-associated skin damage (MASD), and skin changes at end of life. There is growing evidence that these distinct skin conditions are associated, eg, moisture-associated skin damage as a risk factor for pressure injuries/ulcers3 or synergistic, concomitant reductions in skin tears and pressure injuries/ulcers.4 Providers should prioritize an integrative approach to skin frailty, tackling the main risk factors for these conditions (eg, maceration, immobility, medical equipment) synergistically.5 This would represent a new approach, moving away from a siloed way of thinking, and considering all of these conditions in the broader context of skin frailty, reducing overall risk and incidence and improving patient outcomes. The aim of this column is to define the concepts related to skin frailty and vulnerability to injury and guide clinicians in their efforts to identify shared risk factors for skin conditions and ways to maintain or promote skin integrity. KEY CONCEPTS There are a number of factors that can lead to skin vulnerability and risk, including age, UV radiation damage, genetic conditions such as ichthyosis (dry skin), some medications, as well as irritants from dressings or ointments, maceration from incontinence, and repeated skin cleansing.6 These factors can be extrinsic, such as environmental damage (eg, sun exposure), or intrinsic, such as the effects of an underlying illness. In addition, these risk factors may be modifiable or unmodifiable.2 To fully understand the concepts of skin frailty and vulnerability to injury, a good understanding of key concepts related to the skin’s barrier functions is required. Stratum Corneum Barrier Function At the stratum granulosum-stratum corneum interface, the lamellar granules fuse with the cell membrane and discharge their content into the intercellular lamellae. Complex enzymatic reactions lead to modifications of the lipid composition of the intercellular space (cholesterol, ceramides, free fatty acids) that provide a very effective water-permeability barrier.7 Removal of the lipid component by repeated washing with detergents/soaps can lead to conditions such as irritant contact dermatitis.2 Transepidermal Water Loss Transepidermal water loss is the rate at which water vapor is lost from the skin. In healthy skin, the epidermis can resist the assault of external irritants and maintain integrity.7 However, in the continued presence of external irritants, damage to the skin barrier occurs, leading to water loss from both the dermis and epidermis. Accordingly, it is important to maintain the protective acid mantle and skin lipids to reduce the risk of dryness and damage. Acid Mantle The purpose of the skin’s acid mantle is to shield the epidermis from bacteria and pollutants; it also helps regulate the skin’s natural sebum and water balance. This mantle is composed of perspiration as well as oil from sebaceous glands. To protect the acid mantle, the optimum pH of the skin is 4.5 to 5.5. A higher pH–that is, a more alkaline environment–breaks down this protective mantle, allowing bacteria and external irritants to enter the tissues.8 FRAILTY SYNDROME AND SKIN FRAILTY Frailty syndrome is a physiologic condition resulting from the cumulative decline of multiple organ systems, resulting in lower quality of life (QoL) and higher risk of death, hospitalization, and institutionalization. This syndrome occurs most frequently among older adults and in the presence of chronic illness. Rockwood and Mitnitski9 stated that frailty syndrome represents the concomitant interplay of physical, psychological, social, environmental, and economic factors such as aging, sun exposure, and/or genetics. Therefore, frailty syndrome is dynamic, and the effects can be transient or chronic. Fried and colleagues10 noted that frailty syndrome is a condition that meets any three of the following five criteria: low physical activity, weak grip strength, low energy, slow walking speed, and unintended weight loss. Some healthcare professionals use a risk index developed by Rockwood and Mitnitski to assess the presence of frailty syndrome.9 This index is a proxy measure of aging and risk of negative outcomes determined by counting the number of accumulated deficits (disability, diseases, physical and cognitive impairments, psychosocial risk factors, geriatric syndromes [eg, falls, delirium]) out of the total number of age-related variables of health considered. Weakness is the most common manifestation first observed and precedes exhaustion and weight loss about 75% of time.9 Conditions that can lead to increasing frailty include falls/fractures, depression, lowered testosterone, cognitive impairment, hypothyroidism, inflammation/muscle strength, type 2 diabetes mellitus, lowered blood clotting activity, poor nutrition, coronary heart disease, and arthritis. Frailty syndrome is accompanied by symptoms of weakness, fatigue, anorexia, undernutrition, weight loss, low muscle mass, balance and gait abnormalities, and severe deconditioning. Adverse outcomes include falls, injuries, acute illnesses, hospitalizations, disability, dependency, institutionalization, and even death. Etiologic risk factors include age, genetics, lifestyle, diseases, and environment.11 Previously, frailty syndrome has been used as a broader surrogate or synecdoche for skin frailty. One way to aggregate the effects of frailty syndrome on the skin is via the concept of skin frailty. With this integrative approach to frailty and skin, the focus is on acknowledging skin as important and promoting the optimal condition of the skin.10 PROMOTING SKIN HEALTH AND PREVENTING SKIN INJURY Focusing on the importance of the skin, particularly in individuals with vulnerable skin, optimizes good skin integrity outcomes. Skin frailty is complex and a holistic approach is required to prevent skin injury, prioritizing individual needs and preferences. Providers should understand the intrinsic and extrinsic risk factors of skin frailty as well as the need for ongoing assessment and evaluation and have the ability to develop and deliver evidence-based, person-centered care. Assessment It is vital to consider the overall picture of individuals, including mobility, nutrition status, and socioeconomic and psychosocial factors. A full holistic skin assessment should be conducted at the first visit or on admission to the clinical setting. Integrated and complete documentation of the daily care regimen is important to ensure that any changes in the individual’s skin status are identified.12 In addition, an individual’s overall medical and skin-specific history (eg, skin conditions, previous damage) is an important element of assessment and should be taken into account. If family or caregivers are involved, they can also be educated in skin care and how they can help.12 Skin Care Regular moisturizing is a vital part of skincare in individuals with skin frailty to promote general skin health and reduce the risk of skin damage.12 This can help to restore the barrier function of the skin, reduce itching, and increase the level of hydration. Moisturizers can help prevent certain forms of skin damage including skin tears and superficial pressure injuries/ulcers.4,13 Moisturizing products are available in various formulations (creams, ointments, and lotions), as well as liquid body wash and gels (which should be pH-balanced, fragrance-free, and nonsensitizing).6 A full skincare plan is recommended for suitable individuals.6 Self-care Involving the individual in their own care is key to the success of any care regimen. Patient choice and acceptability are particularly important in emollient product selection. The properties and benefits of emollients can vary and be suitable for different individuals–for example, emollients containing humectants may be more cosmetically acceptable for some individuals.12 Nutrition and hydration are key to skin health and can help prevent skin damage. Mobility should also be encouraged wherever possible. In addition, polypharmacy issues should be considered because some medications can cause changes to the skin that require management.14 IMPLEMENTING A PROGRAM TO CHANGE PRACTICE For a skin health promotion program to be successful, careful implementation planning is required. Knowledge translation into practice comprises multiple steps, with varying degrees of complexity depending upon the context. Frameworks are extremely useful for evidence implementation into practice because they facilitate translation, identify barriers and facilitators to successful implementation, structure planning, and enable testable and useful interventions.15,16 For example, the knowledge to action (K2A) framework provides a structured guide for the development and implementation of a population-based skin tear prevention program. Healthcare providers can use the K2A framework to identify available knowledge and gaps in the literature, factors required to adapt a program to the local context, potential barriers and facilitators, methods to evaluate and support self-management, as well as assess the program’s outcomes and sustainability. The K2A framework is comprehensive and dynamic and has been adopted and accepted by the World Health Organization.17 The framework invites healthcare professionals to follow the cycle of knowledge creation and application.17 Successful skin health programs are based on credible evidence and evaluated on a continuing basis, ensuring program objectives are met. Ongoing epidemiologic studies are imperative to better understand the true impact of disruptions in skin integrity, identify modifiable risk factors, monitor the impact of a primary prevention program, and form a basis for gap assessment.18 In keeping with the K2A framework, a variety of stakeholders must be involved to ensure that studies are designed to capture interprofessional concerns as well as necessary data.18 Nurses and other healthcare providers play a major role in identifying behaviors critical to health and assessing the needs of individuals and groups.19 To improve quality care, an assessment is required to understand current prevention practices at a population, provider, and organizational level.18 This is challenging because of the scarcity of existing skin health evidence to inform quality indicators. Healthcare providers must rely on the knowledge creation phase to develop quality indicators. Given the indifference to skin health often demonstrated by both individuals at risk and healthcare professionals, leaders must facilitate knowledge translation and culture change.20 Prior to program implementation, those heading the initiative must understand the prevailing culture and identify leaders who can facilitate change.19 Evidence uptake is a complex and challenging endeavor; simple dissemination is not sufficient to elicit change. Change requires a collaborative, proactive effort for translation to the point of care.21 Engaging stakeholders and healthcare leaders to customize best practice guidelines for the promotion of skin health can improve acceptance and utilization.21 Understanding facilitators will enable healthcare providers to foster and maximize support for the implementation of a skin health program and identifying barriers will allow for development of effective strategies to overcome or mediate roadblocks early.22 To identify these, healthcare providers can use interviews; focus groups; and knowledge, attitude, and practice surveys.22 Limited scientific data support the impact of skin health on older adults. This dearth of research will likely be a primary obstacle to recruiting support and funding from organizations, and researchers must study the impact of skin integrity disruptions among older adults to demonstrate the need for primary prevention programs. Improved skin health is the cornerstone of prevention23 and protecting skin from trauma among older adults in the community should ultimately reduce wound prevalence. The balance of facilitators and barriers is one of the most important aspects determining the success of program implementation efforts and long-term sustainability.24 Healthcare professionals have reported that organizational support is vital for participation in primary prevention programs.25 Implementation strategies must incorporate the facilitators and barriers specific to the organization’s culture to ensure that prevention efforts meet the needs of the individuals at risk and accommodate the agenda of the healthcare system.26 Further, health promotion requires individuals to initiate and maintain health behavior changes. For this to occur, prevention strategies must be tailored to the individual and/or population at risk. Healthcare providers, and particularly nurses, will need to support implementation efforts because they are well positioned to be leaders, influencing and facilitating behavioral change related to prevention.22,24 Program Evaluation Understanding which aspects of nursing care or intervention are successful in bringing about positive changes in individual health status is necessary for identifying the results of nursing practice and designing initiatives aimed at improving the quality of care.27 Standardized measures are essential to evaluate these nursing interventions and implement quality improvement initiatives.28 Measurement of relevant quality indicators demonstrates the relationship between healthcare costs, the care process, and the resulting outcomes. Linking outcome achievement to specific nursing interventions is essential to determining the appropriateness of care provided and identifying which nursing interventions are associated with particular outcomes.29 Sustainability The implementation of programs delivering high-quality care at an acceptable cost is essential if systems are to meet the healthcare demands of larger aging populations; unfortunately, program sustainability varies.30 Models to enhance the sustainability of a skin health program should be incorporated into implementation and should take into consideration the (1) health needs of the target population and expected benefits, (2) effectiveness of the system to monitor progress, (3) adaptability and alignment of the process, (4) multilevel and collective leadership, (5) financial and human resources and (6) stakeholder support.31 CONCLUSION It is imperative to improve skin integrity in individuals with skin frailty. A holistic, person-centered approach to skin health can break down siloed care and improve skin integrity outcomes and quality of life in older adults. Essential elements in this approach to skin care include thorough assessment and continued monitoring as well as thoughtful consideration of multiple, interrelated factors encompassing individual needs and preferences, general health and continence status, mobility, nutrition, and socioeconomic/psychosocial issues. There is a need for increased awareness about the skin and its importance to overall health in specific patient groups at risk of skin damage because of frailty.1,6,10,12,32 The skin is an important indicator of overall health and wellbeing. These authors encourage a way of thinking that encompasses all aspects of skin health, viewing issues through the lens of skin frailty rather than as separate conditions. Improving skin health is a huge opportunity to prevent several complications that may otherwise go unaddressed. Although this article has focused on specific skin injuries and their synergistic risk factors, there are many more. There is also huge scope for individual involvement from patients and their carers/relatives. Self-care regimens and knowledge translation into programs for at-risk individuals can have a beneficial effect on outcomes both in terms of patient health and quality of life, and as a relatively low-cost way of improving systems and realizing cost savings.33

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