The Journal of Nutrition, Health & Aging©
Volume 5, Number 1, 2001
THE JOURNAL OF NUTRITION, HEALTH & AGING©
A FOLLOW-UP STUDY OF ULCER HEALING, NUTRITION,
AND LIFE-SITUATION IN ELDERLY PATIENTS WITH LEG ULCERS
U. WISSING, A.-C. EK, M. UNOSSON
Department of Medicine and Care, Division of Nursing Science, Faculty of Health Sciences, Linköping University, Sweden. Correspondence: Ulla Wissing, Linöping University,
Campus Norrköping, Faculty of health Sciences, 60174 Nooköping, Sweden. Tel: 46 11 36 35 30. Fax: 46 11 12 54 48. E-mail: [email protected]
Abstract: This study was undertaken in order to follow up ulcer healing, ulcer recurrence, nutritional status
and life-situation in elderly patients with leg ulcers. Of 70 patients assessed previously in 1996, 43 (61%)
were still alive in 2000 and, of these, 38 (88%) participated in the follow-up. Rate of healing, recurrence and
amputation were obtained from medical records and interviews with the patients. The Mini Nutritional
Assessment (MNA) was used to assess their nutritional status and the Philadelphia Geriatric Center
Multilevel Assessment Instrument was used for assessment of their life-situation. Nineteen patients (50%),
mean age 82±4.6 years, had healed ulcers. Two (5%) patients, mean age 86±2.8, had required amputation and
had no ulceration after surgery. Seventeen patients (45%), mean age 80.3±6 years, had open ulcers, six had
their original ulcers still unhealed, and 11 had open recurrent ulcers. Decreased mean MNA scores, as well as
decreased mean scores in ADL and mobility, were seen over time in patients with open ulcers but not in
those who were healed. Patients with healed ulcers had significantly higher mean scores in social interaction
than those with open ulcers and significantly increased mean scores in environmental quality over time. The
results indicate that nutrition and the life-situation might be related to leg ulcer healing. The nutritional
situation and the whole life-situation should be observed and taken into consideration when care is planned.
Additional research is needed to increase the understanding of the relationship between nutrition, lifesituation and ulcer healing.
Key Words: Elderly, aging, nutritional status, nutrition, life-situation, leg ulcer healing, follow up
Introduction
Leg ulcers are common in the ageing population. The point
prevalence of open leg ulcer has, in Sweden, been estimated at
1.4 % in the retired population, 65 years and older (1). Most
elderly patients with leg ulcers are living at home and treated
within the primary health care system (2,3). Leg ulcers are
known to have a long healing time and after healing often
recur. In one study, 17 % of the patients had original ulcers
which remained open and 21 % had open recurrent ulcers after
54 months. Patients with venous ulcers had the worst healing
prognosis (4).
Although knowledge about effective treatment regimens has
increased in recent years (5,6), knowledge about the roles of
nutrition and the life-situation in leg ulcer healing remains
limited. Many patients with leg ulcers are affected by pain (2,7)
and have mobility problems leading to dependency on others
for food shopping and meal preparation (8). In recent studies,
poor intakes of energy and nutrients and nutritional deficiencies
in patients with leg ulcers have been shown (9,10). The
consequences of poor intakes may delay ulcer healing since
energy and many nutrients such as proteins, zinc, and vitamin C
play important roles in the wound healing process (11).
Christensson et al. (12) found that leg ulcers and pressure sores
were associated with protein-energy-malnutrition in elderly
people newly admitted to a community resident home (12).
Many researchers state that adequate nutrition is necessary for
optimal effect of medical care (13,14) and wound healing (15).
Nutritional problems, however, often go unrecognised (16,17)
and patients are not always weighed or questioned about their
nutritional situation (18).
In 1996, a group of 70 elderly patients (mean age 79 years)
with leg ulcers, living in the inner city of Norrköping, Sweden,
were recruited into a study on nutrition, health and life-situation
(8,19). The inclusion criteria were: a minimum age of 65 years,
living at home, and receiving treatment for ulcers below the
knee of any cause, and open for more than one month. Thirtytwo of the patients (46%) were assessed as at risk of
malnutrition and two (3%) were malnourished. Malnourished
patients and patients in the risk zone of malnutrition were
usually living alone and more dependent on aids for mobility
and home-help service than the well-nourished. There is no
information available on changes in nutritional status and lifesituation and their relationship to leg ulcer healing over time.
This study was thereforeundertaken in 2000, with the aim of
following up ulcer healing, ulcer recurrence, nutritional status
and life-situation in the patients previously assessed in 1996.
37
The Journal of Nutrition, Health & Aging©
Volume 5, Number 1, 2001
A FOLLOW-UP STUDY OF ULCER HEALING, NUTRITION, AND LIFE-SITUATION IN ELDERLY PATIENTS
Methods
Patients
Of the 70 patients who participated in 1996, 43 patients
(61%). The patients and/or their relatives were given verbal and
written information about the study. One patient was terminally
ill and could not participate. One patient had newly returned
home from hospital. He wished to take part in the study but was
too tired to do so. Two did not wish to participate because they
were disappointed in the health care system and one other gave
no reason. Thirty-eight patients (88%) consented to participate.
Twenty-one (55%) were living alone, seven (18%) had moved
to a community resident home and the others were cohabitant.
The actual diagnoses made by the physicians responsible for
the treatment of the patients, were venous insufficiency in 19
patients (50%). Four (11%) had arterial insufficiency, 4 (11%)
mixed venous/arterial, 2 (5%) diabetic ulcers, 3 (8%)
connective tissue disorder, and 6 (15%) other.
Twenty-three patients had died by the end of 1999 and
during the first months in 2000, an additional 4 patients died.
Of those who died, 13 patients (48%) had venous disease and
14 (52%) other aetiologies. There were no significant baseline
differences in ulcer type or nutritional status between the
surviving patients and the deceased. The surviving patients had,
in 1996, significantly lower mean age, 78±5.6 years versus
81.4±7.1 (p<0.05), lower mean intake of prescribed drugs
3.6±2.4 versus 4.9 ±2.4 (p<0.05), and were less dependent on
home help service (p<0.01) compared with the deceased. When
mortality rate was compared with an approximate death rate for
Norrköping, calculated from the number of inhabitants ≥ 65
years of age 1996 and the number of deaths in the population ≥
65 years of age from in 1996 to 1999, the relative risk of death
in patients with leg ulcer was 1.46 (95% CI 1.05-2.05).
Procedures
The nurses who performed the interviews and the
assessments in 1996, i.e one of the authors (U.W.) and a trained
district nurse, met the patients again in 2000 in the patients'
own homes, or in case of changed type of dwelling, in the
actual community resident home. The same instruments and
methods for measurements used in 1996 were used in 2000.
The study was approved by the Ethics Committee of the
Faculty of Health Sciences, Linköping University.
Data on ulcers
Details of dressing changes, bandages and prescriptions of
analgesia were recorded from the medical and nursing notes.
Individually self-reported data covered ulcer related pain
experienced (yes or no). If the answer was yes the patient was
questioned about occurrence of pain (continuous, at rest/at
night, while mobilising, related to dressing changes). In the
case of healed venous or mixed venous/arterial ulcers, the
patients were questioned about use of preventive compression.
38
Nutritional assessment
The Mini Nutritional Assessment (MNA) was used. The
MNA is a standardised and well-validated tool, developed to
assess the nutritional status in frail elderly people and can be
easily handled in primary health care and nursing homes (20).
The test is composed of 18 point-weighted measurements and
questions, divided into four categories. Anthropometric
measurements include, body mass index (BMI), mid upper arm
and calf circumference. A question about weight loss during the
past three months is included in the anthropometric category.
Global assessment relates to type of dwelling, medication,
mobility, and health problems. Dietary assessment relates to
intake of fluid and food, appetite, and autonomy of feeding.
Subjective assessment relates to self-perception of health and
nutrition. The maximum score of the MNA is 30 points. The
scoring indicates three levels of nutritional status; adequate
nutritional status (well nourished), ≥24 points; at risk of
malnutrition, 23.5 to 17 points; malnourished, <17 points. If the
patient was not able to answer the questions, a relative or a
person from the staff was asked to do so instead (5 patients).
Life-situation
The Philadelphia Geriatric Center Multilevel Assessment
Instrument (PGC MAI) was used to assess the life-situation
(21). PGC MAI assesses behavioural competence in the
domains of physical and functional health, cognition, time use
and social behaviour, and psychological well-being and
perceived environmental quality. The physical health items
relate to self-rated health, health behaviour, and health
conditions. Functional health refers to physical selfmaintenance skills and instrumental activities of daily living.
Cognition includes items related to intellectual function and
cognitive symptoms. Time use is composed primarily of a
checklist of different ways of spending time and social
behaviour includes activities with family and friends with a
focus on social interactions. Items related to personal
adjustment/morale and psychiatric symptoms represent the
sector of psychological well-being. Finally, perceived
environmental quality embodies items about housing,
neighbourhood quality, and personal security at home.
The instrument is interview-based. All items are scored, with
high scores indicating positive values of an individual's life
situation. PGC MAI has been tested for reliability and validity
through several different approaches (21). The intermediate
length version, used in this investigation, contains 68 items
including a demographic part. It has been tested in Swedish
elderly people with locomotive disability. A few items have
been revised for Swedish conditions (22).
Since the PGC MAI assessment is based on the elderly
patient's own answers and actual points of view, five patients
were excluded from that part of the follow-up, as they were not
able to answer all the questions. Of the excluded patients, three
were living in community resident homes, two of them had
healed ulcers and one was amputated and had no ulcers after
The Journal of Nutrition, Health & Aging©
Volume 5, Number 1, 2001
THE JOURNAL OF NUTRITION, HEALTH & AGING©
surgery. The other two excluded patients were still living at
home with home help service. One of these had healed ulcers
and the other had an open ulcer.
Statistical analysis
Statistical methods used in this study were arithmetic mean,
standard deviation, Student's t-test for dependent and
independent groups, and Fisher's exact test.
Results
Ulcer healing and recurrences
Nineteen patients (50%), mean age 82±4.6 years, had healed
ulcers. Two patients (5%), mean age 86±2.8 years, had required
amputation and had no ulceration after surgery. Seventeen
patients (45%), mean age 80.3±6.3 years, had open ulcers, six
(16%) had their original ulcers still unhealed and 11 (29%) had
open recurrent ulcers. In four patients (11%) the ulcers had been
open for longer than 5 years, for two of them longer than 10
years. Proportions of patients with healed or unhealed ulcers did
not differ significantly with regard to gender, ulcer aetiology
(venous-non-venous), mobility (walk freely-restricted mobility)
or nutritional status (well-nourished-risk/ malnourished) (Table 1).
Table 1
Gender, etiologic groups, mobility, and nutrition status in
patients with healed and open ulcers.
Open ulcers
Healed Original Recurrent
n=19
n=6
n=11
Amputation
n=2
Gender
-men
-women
2
17
4
2
3
8
Etiologic groups
-venous
-non-venous
9
10
3
3
7
4
2
Mobility
-walk freely
-walking aids
-wheelchair
8
10
1
4
1
1
2
7
2
1
1
Nutrition groups
-well nourished
-risk of
malnutrition
-malnourished
8
10
1
1
1
Ten patients (26%) had pharmacologically treated diabetes.
Five had healed ulcers, the two amputated patients and three
with venous ulcers. Three patients had their original ulcers
unhealed (two venous and one vasculitis) and two had recurrent
venous ulcers.
Treatment
All patients with open ulcers were following the "Treatment
Programme of Leg Ulcers" (23) run by the Department of
Dermatology, in collaboration with primary health care. The
dressings were changed twice weekly for eight patients, and
once weekly for seven, one patient with venous ulcers had the
dressings changed three times weekly due to heavy exudate and
one patient with a diabetic foot ulcer had the dressings changed
daily. Patients with venous or mixed arterial/venous ulcers used
prescribed compression bandages. Five patients with healed
venous ulcers did not use any kind of compression for
preventing recurrences.
Pain and analgesia
Eleven patients (65%) with open ulcers reported ulcer-related
pain. Seven of these also reported pain in 1996. Four had
continuous pain, two reported pain at night, and dressing
changes were considered painful by the others. Six patients,
including one who had undergone amputation, reported pain in
the healed legs when walking or at night. Three of these
reported pain in 1996. The number of patients who were
prescribed analgesia was 19 (50%) in 1996, and 20 (53%) in
2000, including twelve patients (71%) with open ulcers, all
reporting pain, as well as eight of the patients (37%) with healed
ulcers.
Nutritional status
According to the MNA, 29% were assessed as wellnourished, 58% in the risk zone of malnutrition and 13% were
assessed as being malnourished (Figure 1). Eighteen patients
had deteriorated in nutritional status. Two patients with healed
ulcers assessed as being at risk of malnutrition in 1996 had
altered to well-nourished.
Figure 1
The number of patients who were assessed as well nourished,
as at risk of malnutrition and malnourished in 1996 and in 2000.
Year 1996
Year 2000
Nutrition groups
n=38
n=38
Well nourished
24
Risk of malnutrition
13
3
6
5
3
9
14
1
2
8
11
22
3
1
1
Malnourished
39
1
7
5
The Journal of Nutrition, Health & Aging©
Volume 5, Number 1, 2001
A FOLLOW-UP STUDY OF ULCER HEALING, NUTRITION, AND LIFE-SITUATION IN ELDERLY PATIENTS
The total mean MNA score for all patients had decreased
from 23.9±2.8 in 1996 to 21.7±4.6 in 2000 (p<0.01) and mean
BMI value from 26±5.1 to 25.1±6 (p<0.05). The patients with
healed ulcers did not show any significant changes from 1996
to 2000 in mean scores in any MNA category but the group
with ulcers had decreased in all MNA categories except in
subjective assessment of own health and nutrition (Table 2).
Table 3
Group means ± SD in patients with healed and open ulcers
for domains in the sector of behavioural competence in PGC MAI.
Table 2
Anthropometry and MNA scores in 1996 and in 2000 in
patients with healed and open leg ulcers.
Healed
n=21
1996
2000
Healed
n=17
Open ulcers
n=17
1996
Scale range 1996
2000
1.65±0.1 1.64±0.1
1.66±0.1 1.65±0.1
71.1±15.6 67.1±16.5* 71.7±16.4 69.4±18.9
26±5.3
25±6.2
26.1±5.1 25.4±5.9
MNA assessment (maximum 30 points)
anthropometric 6.8±1.5
(8 p)
global (9 p)
7.4±0.8
dietary (9 p)
6.6±1
subjective (4 p) 3.1±0.7
Total MNA
23.9±2.7
score
6.6±1.7
7.4±1.3
6.1±2.3*
7.2±1.8
6.1±1
3±0.8
23±3.8
7.2±0.8
6.3±1.2
2.9±1
23.8±3
6.4±1.2*
5.1±1.6**#
2.7±1.1
20.4±4.7**
2000
Open ulcers
n=16
1996
2000
Physical health (7-19) 14.5±2.1 14.2±1.9 14.2±1.6 13.5±1.8
domain index
Anthropometry
Height
Weight
BMI
in any of the domains but the patients with ulcers scored
significantly lower over time in the mobility domain as well as
in activities of daily living.
Patients with healed and open ulcers did not differ
significantly in any domains in 1996 or in 2000 except in the
social domain in 2000 (Table 3).
Comparison within groups over time, t-test, dependent groups; *p<0.05, **p<0.01.
Comparison between patients with healed ulcers and patients with open ulcers in 2000, ttest independent groups #p<0.05
In 1996 no differences in anthropometric measurements and
MNA categories between the healed and the non-healed groups
were found. In 2000 the mean MNA total score was higher in
the healed group but statistical significance was not achieved
(p=0.07). Patients with healed ulcers had significantly higher
mean MNA scores in dietary assessment than patients with
open ulcers (Table 2). The mean MNA total score in the
patients living in community resident homes, differed
significantly from those still living at home 16±3.2 versus
23±3.8 (p<0.001). No significant differences in mean MNA
total score between patients reporting pain or those without
pain or between patients with or without diabetes were found.
Life-situation
Behavioural competence. The healed patients had no
significant changes from 1996 to 2000 in mean PGC MAI score
40
Activities of
daily living
domain index
(4-12)
9.8±2.3 9.5±2.6 10.2±2.5
9±3.1*
Mobility
domain index
(2-16)
8.9±3.2 8.6±2.9 10.2±3.8 7.8±4.5*
Cognitive
domain index
(0-5)
5±0
4.3±1.5 4.8±0.5 4.8±0.8
Time use
domain index
(7-50) 14.6±6
12.1±3.9 12.7±4.5 12.6±5.1
Social
domain index
(4-48) 20.8±6.6 21.9±6 17.1±5.9 16.8±3.9#
Comparison within groups over time, t-test, dependent groups; *p<0.05. Comparison
between patients with healed and open ulcers in 2000, t-test independent groups; #p<0.05
Of the 30 patients, still living at home, 11 (37%) received
home help service. Seventeen (57%), received help from either
the home-help service or relatives with food shopping. Four of
these could do their own shopping but needed assistance with
transportation. Six patients (20%) had a cooked meal delivered
daily. Proportions of patients with healed and unhealed ulcers
did not differ significantly with regard to whether they received
home-help service or not, were able to shop or not, or whether
they received meal support or no meal support.
Psychological well being and environmental quality
In the patients with healed ulcers a higher scoring in
subjective housing and subjective neighbourhood could be seen
over time. Otherwise, there were no significant differences
between the groups in 1996 or 2000 or changes over time in the
ulcer group (Table 4).
The Journal of Nutrition, Health & Aging©
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THE JOURNAL OF NUTRITION, HEALTH & AGING©
Table 4
Group means ± SD in patients with healed and open ulcers
for items in the sectors of psychological wellbeing and
perceived environmental quality in PGC MAI.
Healed
n=17
Scale range 1996
Psychological well being
Morale
(0-5) 2.8±1.3
Psychiatric
(0-3) 2.3±0.7
symptoms
Open ulcers
n=16
2000
1996
2000
2.9±1.1
2.4±0.9
2.9±1.3
2.6±0.7
3.2±1.4
2.6±0.6
Environmental quality
Subjective
(5-15) 13.7±1.4 14.5±1.2* 14±0.8 13.8±1.9
housing
Subjective
(5-16) 13.3±1.9 14.2±1.6* 14±1.5 13.8±1.9
neighbourhood
Personal
(2-4)
3.9±0.5
4±0
4±0
4±0
security
Comparison within groups over time, t-test dependent groups; *p<0.05
Discussion
The frequency of unhealed original ulcers (16%) and open
recurrent ulcers (29%) was not unexpected since findings of
poor healing and high recurrence rate have been presented
earlier (4). In this study, ulcers had been open for longer than 5
years in four patients (11%). The high frequency of open and
recurrent ulcers may be influenced by other factors in addition
to clinical and medical history.
Many health care providers are today aware of issues related
to the life-situation and their importance for healing and
recovery. Such an issue associated with wound healing may be
the nutritional situation (12,15). In this study, the patients with
healed ulcers had no significant changes in any MNA category
over time as compared with ulcer patients. They had
significantly higher mean MNA scores in dietary assessment in
2000 than did patients with ulcers. The reason, which is open to
question, why the amputated patients were put into the group of
patients with healed ulcers, was that their wounds were healed
after surgery. However, reduced MNA scores in most MNA
categories were found over time in patients with open ulcers.
The results suggest that there may be a relationship between leg
ulcer healing and nutrition.
It is known that malnutrition is linked to morbidity in the
elderly (24) but also related to the social situation of having
disease with restrictions on physical capacity and social
activity, isolation and poor dietary intakes (25). Christensson et
al. (1999) found that leg ulcers, as well as pressure sores were
associated with protein-energy malnutrition in elderly patients
newly admitted to a community resident home (12). It may be
that living with poor ulcer healing, as well as recurrence is
associated with a decrease in dietary intake and poor nutritional
status. The nutritional situation should be more closely
observed in frail elderly patients with leg ulcers, since wound
healing is a process where the nutritional needs of the body
may be increased (11). More could be done to identify those
who need help with meal support. Use of enriched meals and
dietary supplements may be necessary to ensure adequate
intakes in the frailest elderly patients still living at home and
receiving treatment there. At least it is essential that patients at
risk of malnutrition are followed up regarding their nutritional
situation and that patients, care givers and relatives involved in
food shopping receive information about foods containing
nutrients important for wound healing. More could also be done
about the nutrition routines in geriatric care since eating
disturbances, morbidity and higher dependency are common in
elderly patients living in institutions (24).
Pain was a common problem. Pain is often an
underestimated problem in patients with leg ulcers (2,7) and
does not necessarily indicate presence of arterial disease or
infection (26). With adequate management of pain, the patient
may be more motivated into physical activities within his or her
abilities and one of the problems in the life situation (19) may
be reduced. Pain relief is thus not only important to make a
patient’s life more comfortable, but is also likely to play an
important role in activity, nutritional situation, and in the
healing process.
Once healed, use of compression stockings or compression
bandages to prevent recurrences in patients with venous
insufficiency is at least as important as to achieve primary
healing. In this study, five patients with healed ulcers did not
wear their prescribed stockings. The support of healed patients
ought to be influenced by the preferences of the patients. It has
been seen that a high proportion of patients are unable to put on
the stockings in the morning or take them off in the evening
and there is a high incidence of skin irritation (27). A practical
arrangement to ensure a proper compression in patients with
restrictions in mobility, could be weekly follow-ups by the
district nurse for skin care and bandaging of the legs when
stockings are impossible for the patient to apply. Poor mobility,
which was common in this study, is less easy to influence in
such elderly patients but activities for those who mostly sit such
as moving the feet up and down at regular intervals, should be
encouraged to prevent the ankle joint becoming stiff. Some way
of measuring these activities would be an advantage both in
order to encourage exercise by setting goals and to provide
material for the nurse to follow up.
The proportion of patients who had moved to some kind of
long-term care institution was 18%, and still living at home
receiving home help care 37%. The percentage, of all elderly
people, 80+ years in Sweden, living in a community resident
home was 22.8 %, and receiving home help care was 19.8% in
1997 (28). This may indicate that living at home with a chronic
41
The Journal of Nutrition, Health & Aging©
Volume 5, Number 1, 2001
A FOLLOW-UP STUDY OF ULCER HEALING, NUTRITION, AND LIFE-SITUATION IN ELDERLY PATIENTS
condition such as leg ulcers might have a marked impact on the
daily life situation, especially in patients with open ulcers who
scored lower in ADL and mobility in 2000 than in 1996. The
patients with healed ulcers scored significantly higher than
unhealed patients in social interaction. It is clearly easier to
interact with other people and to appreciate the housing and
neighbourhood qualities when the ulcers are healed. It is
important to develop care strategies for elderly patients in order
to maintain their ADL performance and promote social
contacts, perhaps with the help of healed patients.
A limitation that should be noted, is the small sample size at
the follow up. At least two of the five non-participants were too
frail to be followed up and 27 patients were dead. The relative
risk of death in patients with all kind of leg ulcers was 1.46
(95% CI 1.05-2.05) which corresponds well with previous
findings (4). According to Nelzén et al. (1997), a higher
mortality is found among patients with non-venous ulcers than
in patients with venous ulcers (4). In this study there was no
significant difference between patients with venous or nonvenous ulcers. It is possible that the numbers were to small to
allow the result to achieve statistical significance.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Conclusion
16.
Decreased mean MNA scores in most categories, as well as
decreased mean scores in ADL and mobility were seen over
time in patients with open ulcers but not in patients with healed
ulcers. Patients with healed ulcers had significantly increased
mean scores in the domain of environmental quality. The
results indicate that nutrition and the life-situation may be
related to leg ulcer healing. The nutritional situation and the
whole life-situation should be observed and considered when
care is planned. Additional research, for example a multi-centre
study including a greater number of patients, is needed to
increase the understanding of the relationship between
nutrition, life-situation and ulcer healing.
17.
18.
19.
20.
21.
22.
23.
24.
Acknowledgements: Grants from, the Research Fund of the County of Östergötland
and the "Vårdalstiftelsen" (96/141, 98/359) are gratefully acknowledged.
25.
26.
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