Impaired Skin Integrity in the Elderly

Jane Ellen Barr, RN, ANP, MSN, CWOCN

For years, clinicians across the continuum of care have focused on the development of programs for the prevention and treatment of chronic wounds. In many situations, clinician time and budgetary restraints have allowed the wound care arena to overshadow the need to develop similar programs for the prevention and management of actual or potential impaired skin integrity, especially in the geriatric population.

According to current US Census statistics,1 the population is getting older — 12% is >65 years and of this group, 5.6% is older than 75 years. As people age, their chances of developing skin-related disorders increase.

More than 70% of the older population has skin conditions.2 Clinicians need to focus on the assessment and management of the elderly with or at risk for impaired skin integrity. Geriatric skin care requires knowledge of the anatomy and physiology of the skin, physiological changes that occur with aging skin that play a significant role in common geriatric skin conditions, skin assessment techniques, and management of common skin care problems. Administrators in acute, subacute, and long-term care settings need to support the development and implementation of facility-wide skin care protocols and product formularies for prevention and management of geriatric skin care problems, as well as ways to maintain skin integrity.

This article addresses various aspects of the assessment and management of the most common alteration in elderly skin integrity: dry skin.

The Skin: Structure and Function

The skin is composed of two layers — the epidermis and the dermis, the latter secured to muscle and bone by connective tissue. The two layers have numerous functions.3 The primary function of the epidermis is to maintain skin integrity by presenting a physical barrier to micro-organisms, physical insults, and toxic agents. Skin pH (slightly acidic) and the Langerhans cells (functioning as macrophages by processing contact antigens before T lymphocyte assimilation) provide the micro-organism barrier. The melanin in the basal layer protects the skin from the physical insult of ultraviolet radiation.

The dermis, which provides strength, support, blood, and oxygen, is comprised of sweat glands, sebaceous glands, hair follicles, and small fat cells. Sebum, secreted by the sebaceous glands, maintains skin hydration by providing a protective lipid layer that minimizes fluid loss through the epidermis.

Subcutaneous tissue (the fatty layer) beneath the dermis functions as a shock absorber against trauma, provides high-calorie storage, and modulates conductive heat loss. It attaches the dermis to the underlying structures, facilitating its ongoing blood supply for regeneration.

Aging Skin and Moisture Retention

Aging has a significant impact on the structure and function of the skin and its ability to retain moisture. Changes in aging skin (eg, decreases in production of lipids, desquamation rate, and dermal proteins; changes in lipid composition; and prolonged epidermal turnover) decrease the skin’s ability to retain moisture.


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