Case Study 1:
individual with a suspected venous leg ulcer, uncontrolled oedema and cognitive impairment (dementia)
The case has been described by Dr Kirsti Ahmajärvi, Department of General Practice and Primary Health Care, University of Helsinki, Helsinki, Finland
Patient details: 86- year-old lady with hypertension (difficult hypertension and symptoms of orthostatism and vertigo), dyslipidemia, coronary artery disease, osteoporosis, cerebellar infarction and vascular dementia.
The presenting wound is shown in Figure 1 and Figure 2 shows the periwound area.
Initial wound diagnosis: The patient was first treated for a venous ulcer with associated lower limb oedema associated.
Skin Care: Chlorhexidine- betamethasone- skin cream daily for the periwound skin.
Medication: Acetyl salicylic acid 100mg daily, bisoprolol 2,5mg x1, ferro glycine sulphate 100mg x1, furosemide 20mg x1, cholecalciferol 20mg daily, candesartan 16mg daily, rosuvastatin 10mg daily, spironolactone 6,25mg daily. The patient was taking paracetamol 500mg 3 times daily.
Nutrition: The patient was receiving nutritional supplementation to help with wound healing.
Part 1: Initial assessment
The Clinical Frailty Scale was used as part of the patient’s assessment. The result was a score of 6, which indicates that they were moderately frail – and describes a person who needs help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance (cuing, standby) with dressing.
| Practice point: Functional assessment tools such as the Activity Daily Living test (ADL Barthel index/test) can be used to identify the ability of the individual to perform daily activities and the potential level of collaboration with health workers. |
A Numerical Rating Scale (NRS) (0-10 points) for pain was used as part of the assessment. However, the patient was unable to use the scale to indicate any pain or discomfort.
Further Reading: Holistic Management of Wound-Related Pain
The patient’s Body Mass Index (BMI) was 21, and she weighed 54kg. Her recent fasting plasma Cholesterol Low – Dense – Lipoprotein-level was 1.2 mmol/l.
The Mini-Mental State Examination indicated a score of 22 which indicated the patient had cognitive impairment, but was still able to live at home with home care. The patient appeared orientated, however memory difficulties occurred when asking past experiences of pain, but she was able to provide an indication of the present situation and pain experience.
The patient had daily home care visits (once per day) and needed a walking assistance device.
The Community Nurse made a request for the GP to review the patient at home.
Part 2: Initial symptoms and treatment
The patient has had longstanding oedema in her legs which worsened over time and caused ulceration of the gaiter area of both legs. The left leg was worse than the right. There were no signs of lipodermatosclerosis but dermatoporotic skin was evident
| Practice point: Dermatoporosis describes an extreme cutaneous insufficiency / fragility syndrome. It is common in the elderly (Kaya et al 2022). |
The GP commenced diuretics to treat the lower limb oedema and compression bandages were applied to treat the venous disease. A hydrogel dressing was used for local wound management as the ulcers were sloughy and a secondary dressing was used to keep the gel in place.
The patient’s leg oedema persisted despite use of compression therapy and over time the patient’s adherence to compression therapy decreased. The patient did not seem aware or completely understand the purpose of using compression and kept taking the bandages off. The ulcers became very painful over time which led to decreased adherence to the treatment. The ulcers deteriorated and the patient reported increased pain, particularly in her left leg.
Part 3: One month later
The ulceration became worse (Figure 3), and the patient’s pain increased, particularly when debridement of the ulcer was attempted. This was despite the GP using local lidocaine and xylocaine during the procedure. Paracetamol was not sufficient to manage her pain, and the patient was still unable to tolerate compression bandaging. The patient felt that the ulceration had worsened because of the compression bandages.
The home care nurse undertook a vascular assessment (pulse palpation and measurement of the Ankle Brachial Pressure Index (ABPI) with a hand-held doppler and blood pressure monitor). Pulses were present, but reduced, there were no signs of critical limb ischaemia or gangrene, the limbs felt cool but not cold. The nurse was unable to measure the ankle brachial pressure index due to the presence of pain in both legs.
Further Reading: Lower Leg Ulcer Diagnosis and Treatment Document (Isoherranen et. al 2023)
Part 4: Second month
The GP visited the patient and observed pitting oedema up to the thigh region; no compression therapy was being used. The left lower leg gaiter area had five separate circular wounds, approximately 2-3 cm size, the largest wound was 6cm x 3cm (Figure 4). Fibrin was visible on all the wound beds. The ulcers had been treated at home for two months with no progression and had worsened since the compression bandaging had stopped. It was still not possible to undertake a vascular assessment due to the patient’s level of pain. Pulses were still present, albeit reduced, and there were no signs of critical limb ischaemia or gangrene.
Further reading: Evidence For Person-Centred Care in Chronic wound Care – EWMA
The GP made a referral to the Emergency Department (ED) based on the deterioration of the ulcers and the associated pain.
Part 5: Acute admission to hospital
The patient was evaluated in the ED: the presence of pain and the clinical features indicated a diagnosis of a wound infection with some spreading cellulitis. Treatment included intravenous antibiotic cloxacillin 2g x 4. In addition, there was an absence of peripheral pulses, therefore an urgent referral to a vascular surgeon was made.
The patient had difficult hypertension and was taking several medications (bisoprolol, 2,5mg x2, felodipine 2,5mg x1, furosemide 20mg x1, candesartan 16mg x2, spironolactone 6,25mg x1).
Based on her reported pain she was prescribed an opioid analgesic (Oxycodone 5mg every 12 hours).
The patient was reviewed by a Vascular Surgeon who undertook an ABPI which was 0.70/0.67, toe pressure was 53/34 and pulse curves were low-shaped. Her arterial femoralis pulse was palpable, but peripheral pulses were non-palpable. Magnetic Resonance Angiography (MRA) of the arteries showed severe arteriosclerosis and stenosis in both sides of the main arteries. There were no possibilities to proceed to a bypass procedure nor endovascular treatment due to patient’s general condition. A diagnosis of mixed venous and arterial ulceration was made.
Treatment of the ulcers included gentle debridement and light compression therapy (2 cotton rolls, with only one elastic bandage). Optimal pain medication and local treatment were also part of the treatment. Due to persistent pain and enlargement of the ulcers (Figure 5) biopsies were taken to rule out the presence of Martorelli ulcers. These results were negative for this condition.
Practice point: Watch the video. What are the key considerations in planning the patients discharge from hospital to home, with regards to pain medication specifically?
Part 6: Following discharge
The patient was discharged home with light compression therapy and local wound care (foam dressing was used initially and later non-adhesive dressing).
Once home, the patient reported no pain at rest (0 on the NRS), only feeling pain when walking or during wound management and debridement (procedural pain) which was rated as 9-10 on an NRS scale. The pain medication was reviewed: Oxycontin was eventually stopped and Gabapentin 300mg x3, Paracetamol 500mg x3 were continued. These were sufficient to control the patient’s pain.
Practice point: Watch the video. What ongoing assessment and management of pain is needed for this patient? How might you assess the functional ability of the patient and the impact of pain and analgesia?
Conclusion
Home care is essential in the treatment of patients with lower leg ulcers as the treatment involves the use of compression therapy which requires careful monitoring. Challenges related to pain assessment, differential diagnoses and treatment of chronic ulcers are common among patients with dementia or mild cognitive impairment. These individuals have challenges in understanding and following instructions for wound care and/or co-operating with the home care personnel.
This case showed that there were diagnostic challenges in a patient with painful leg ulcers. Ultimately it was established that the patient had mixed arterial and venous disease. Suspicion for mixed aetiology arose from the patient’s vascular comorbidities including uncontrolled hypertension, coronary artery disease and cerebellar infarction. A poor response to medication to control hypertension is also a risk factor for Martorelli ulceration and therefore this needed to be excluded as a reason for the ulcer.
Sufficient pain assessment and treatment is required. Unidimensional pain scales are useful, but regarding patients with poor cognitive function useful tools might also include the Pain Assessment in Advanced Dementia (PAINAD) Scale and multidimensional tools which are helpful in evaluating the pain. Modified compression therapy as well as treatment of procedural pain were key factors in this case.