Skin aging is associated with inevitable anatomical and physiological changes. For example, epidermal and dermal tissue layers become thinner, mechanical strength is reduced, epidermal turnover rates decrease, sweat and sebum are reduced, and skin surface pH is elevated with aging. These skin barrier changes lead to increased susceptibility to skin injuries (e.g., superficial ulcerations, skin tears) and dermatoses (e.g., xeroses, fungal infections) (Chen & Yesudian, 2013; Jafferany, Huynh, Silverman, & Zaidi, 2012; Seyfarth, Schliemann, Antonov, & Elsner, 2011). Common age-related diseases (e.g., diabetes mellitus type 2, functional impairments [e.g., immobility, incontinence]) further increase the risk for adverse skin conditions, dermatoses, and injuries (Kilic, Gül, Aslan, & Soylu, 2008; Kottner, Balzer, Dassen, & Heinze, 2009).
To maintain and enhance skin integrity and skin health, adequate skin care is a commonly agreed upon goal in geriatric and long-term nursing care (Cowdell, 2011). Recommended skin care strategies involve non-irritating cleansers, emollients, moisturizers, or barrier products to prevent lesions and maintain skin health in aged care (Cowdell, 2011; Surber, Brandt, Cozzio, & Kottner, 2015).
However, recent systematic reviews revealed that the evidence base for skin care interventions for older adults is weak (Cowdell & Steventon, 2015; Hodgkinson, Nay, & Wilson, 2007; Kottner, Lichterfield, & Blume-Peytavi, 2013a), and little is known about daily skin care routines in geriatric care. Only a few reports exist about skin care practice in aged care facilities, indicating large practice variations (Beauregard & Gilchrest, 1987; Cohen-Mansfield & Jensen, 2005; Kottner, Rahn, Blume-Peytavi, & Lahmann, 2013; Meaume, Colin, Barrois, Bohbot, & Allaert, 2005).
The current exploratory investigation aimed to quantify frequencies of skin care interventions performed by nurses in long-term care facilities. Data regarding possible differences related to gender and age were examined. Targeted skin areas per gender and age group were also quantified.
Study Design and Setting
In 2012, a multicenter descriptive, cross-sectional study was conducted in Germany (Kottner, Rahn, et al., 2013). It was part of nationwide prevalence studies about health care problems in long-term care facilities (conducted annually since 2002). At the time of the study, 3,830 residents were living in 47 participating long-term care facilities across the country. Demographic characteristics of the sample were similar to the whole population at this time (Pfaff, 2011).
The current epidemiological study was based on a well-established study design performed in the Netherlands since 1999 (Bours, Halfens, Lubbers, & Haalboom, 1999). Empirical evidence also supports internal and external validity of the annual prevalence studies in Germany (Lahmann, Dassen, Poehler, & Kottner, 2010).
The current study was approved by the ethical committee of the Berlin Chamber of Physicians and was prepared and implemented by the Department of Nursing Science in cooperation with the Department of Dermatology from the Clinical Research Center for Hair and Skin Science.
Procedure (Data Sources and Measurements)
All residents living in one of the participating long-term care facilities at the time of the survey were invited to participate. Inclusion criteria were age 60 or older and consent from the potential participant or his/her proxy after being informed about the study procedures and confidential data collection. Two hundred ten (5.5%) residents refused participation and 69 (1.8%) were unable to participate due to health conditions.
Before conducting surveys on-site, each participating institution appointed a study coordinator who selected teams of two qualified nurses. Teams were trained using instruction materials, including procedures, definitions, diagnostics scores, and images, to accurately fill in the written questionnaires. At the time of data collection, rater teams physically examined participants and screened their records.
Written questionnaires were created with Cardiff TeleForm. High standardization and simplicity were key design concepts to minimize risk of non-response bias. In addition, partly redundant questions were incorporated for internal validation purposes. However, one limitation was selection bias, given the voluntary nature of the study. It cannot be ruled out that only institutions interested in optimizing their quality of long-term care participated. Furthermore, data from participants with high nursing care needs might have been omitted if they were excluded from the survey due to their health condition or informed consent was denied.
Relevant variables for assessing demographics included gender, age, weight (kg), height (cm), level of nursing care, residents' primary diagnosis, and possible secondary diagnoses of diabetes (yes/no) and/or dementia (yes/no). According to the 11th Book of the German Social Security Code (“Sozialgesetzbuch XI...,” 2015), nursing care levels were classified as 0, I, II, III, or III+ (where 0 = no care dependency and III+ = severe care dependency).
In addition, questions regarding incontinence and degrees of activity and mobility (using the respective Braden scale items [Bergstrom, Braden, Laguzza, & Holman, 1987]) were asked to help understand residents' health conditions. Except for the primary diagnosis item, all questions were answered by checking tick boxes.
Of particular interest were the items regarding skin care. The initial question of the skin care section asked whether the resident performed skin care by him/herself without assistance (yes/no). In case of being partly or fully skin-care dependent, the frequency of skin care applications per day and per week, as well as the body part on which the product was applied, was recorded (three free text responses).
Study Size and Statistical Methods
A formal sample size determination was not conducted. Based on previous studies, the expected sample was considered sufficient to calculate precise point-estimates.
Because the investigation focused on older adult skin care, all residents younger than 60 were excluded from analysis. Residents ages 60 to 84 were classified as aged. Residents 85 and older were classified as old-aged. To detect possible differences in skin care practices between men and women, both groups were further divided into male and female residents, forming four groups in total. Each group was described using age, body mass index (BMI), level of care, and presence of diabetes and dementia, as well as incontinence. Age and BMI were described by means and standard deviations. Classes III and III+ (for level of care) were merged to be comparable with nursing care statistics (Pfaff, 2011).
If data were incomplete for any of these variables, the corresponding participants were excluded from analysis. Frequencies and proportions of level of care; presence of diabetes, dementia, and incontinence; and degrees of activity and mobility were calculated. Subsequently, residents were filtered to determine first how many received a skin care application by nursing personnel and second for how much additional information about treated skin areas was provided.
Based on the Wilson (1927) score method, 95% confidence intervals were computed. For all four groups, body parts treated with skin care applications were quantitatively described. For this purpose, free text responses were iteratively coded in a precedent procedure. A unique identifier was assigned to each listed body part to simplify analysis. In many cases, terminology used for identical or similar body parts differed among the various institutions. In some cases, differently used terms could be consolidated, including: “groin bends” to “groin,” “personal area” to “genital area,” and “torso” to “trunk.” The body parts were then ranked in descending order based on skin care application frequencies.
Table 1 displays the demographic and clinical characteristics of the sample (N = 3,385). The majority of residents were old-aged females. The median age of all participants was 87 years (inter-quartile range = 81 to 91 years).
Demographic and Clinical Variables of Study Sample (N = 3,385)
In general, the proportion of residents with health problems was higher in the aged groups than old-aged groups. Younger residents had higher BMIs, were more often affected by diabetes or dementia, and limited in their activity and mobility to a higher degree. On average, two of three residents experienced urinary and/or fecal incontinence. Old-aged residents more often than aged residents received leave-on skin care products by nurses (aged males: n = 337, 81.4%; old-aged males: n = 308, 88.3%; aged females: n = 665, 84.3%; old-aged females: n = 1,670, 91.1%).
Frequencies of applied leave-on products are shown in Table 2. On average, males and females received skin care applications approximately 14 and 15 times per week, respectively. The top 10 listed body parts were identical for each group, although differed slightly in their ranks, and accounted for >94% of all weekly skin care applications. The full body was the most often treated body part for all groups, comprising more than one third of all skin applications. The second and third most treated body parts were the face and buttocks, respectively. When considering the buttocks and genital area together as a general skin care application zone, it accounted for >15% of all treatments for aged males and old-aged females, and for >10% of all skin care applications for old-aged males and aged females.
Frequencies of Treated Body Parts
Residents who performed their skin care independently (n = 405, 12%) were similar in terms of mean age and gender, but were less care-dependent and had less activity (average proportion of walks frequently = 45.9%) and mobility (average proportion of no limitation = 35.8%) limitations.
Findings from the current study show that skin care in long-term care facilities plays a major role in daily nursing activities. For example, the high prevalence (30% to 85%) of xerosis in long-term care (Paul et al., 2011; White-Chu & Reddy, 2011) might explain the distribution of treated body parts. The entire body received one third of all applications and mostly larger regions of the body (e.g., upper body, lower body, extremities) were listed in the top 10. Pruritus and other infections of the skin can be caused by dry skin (Cooper, Clark, & Bale, 2006; Grundmann & Ständer, 2010), causing need for protective skin care strategies. A recently published skin care algorithm (Lichterfeld et al., 2015) recommends two or more applications per day in these cases. However, another study revealed that, most of the time, only one application per day is performed, suggesting an undersupply for these types of skin conditions (Kottner, Boronat, Blume-Peytavi, Lahmann, & Suhr, 2015).
In addition, skin tears and superficial pressure ulcers (typically resulting from limited mobility and activity; approximately 40% of residents) show a varying prevalence of 2% to 40% (Kottner, Dassen, & Lahmann, 2010, 2011; LeBlanc & Baranoski, 2011; National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2009), and thus present another probable cause for the high amount of skin care applications on larger regions.
Another observation is that the high proportion of skin care applications in the genital area and buttocks is highly related to the prevalence of incontinence-associated dermatitis (Kottner, Blume-Peytavi, Lohrmann, & Halfens, 2014; Long, Reed, Dunning, & Ying, 2012). Incontinence episodes place individuals at risk for incontinence-associated dermatitis (Kottner et al., 2013a,b).
The high proportion of skin care applications on the legs and lower limbs may have resulted from residents with diabetes mellitus (∼28%), as it is often associated with xerosis, especially in combination with advanced age (Piérard et al., 2013).
The current findings indicate that the face also plays an important role in daily skin care (men = rank 3, women = rank 2). In general, facial skin is composed of fewer corneocyte cell layers than other body areas, with higher transepidermal water loss (Kottner et al., 2013b), indicating a vulnerable skin barrier (Tagami, 2008; Ya-Xian, Suetake, & Tagami, 1999). In addition, the face is usually not covered by clothes, making it more exposed to environmental factors (e.g., ultraviolet light [Fischer, Talwar, Lin, & Voorhees, 1999]) than other body areas. Moreover, facial appearance has important psychosocial implications, especially for women (Gupta & Gilchrest, 2005). Men usually expose their face to mechanical stress due to regular shaving procedures. Thus, increased facial skin vulnerability and desire for fresh and well-groomed skin might explain the overall high frequencies of facial product applications.
Although 90% of residents were treated with leave-on products, information for less than two thirds of treated body parts were available. Moreover, proportions of completed data collection forms for the body parts differed among the four groups. However, given a homogenous distribution of the relative frequencies within these groups and the fact that the observed data are coherent with the observed demographic and clinical data, the results were assumed to be generalizable.
Findings from the current study suggest leave-on product use is common in nursing homes. The most important question for clinical practice and research is now: Which skin care strategies work best to maintain skin integrity and enhance well-being and comfort in geriatric patients?
In the current study, a detailed quantification of skin care application patterns in long-term institutional nursing care from an epidemiological and health service research perspective was provided for the first time. Results indicated skin care interventions play a substantial role in daily geriatric nursing practice. However, evidence-based guidance is rare and it remains unclear whether the applied treatments are appropriate for the skin conditions. Not every lotion, moisturizer, or ointment is suitable to treat dry skin, dermatitis, or other forms of skin irritation. Several factors, such as pH gradient, ingredients such as humectants, or the lipophilicity of the product, might influence the result and depend on the condition of the skin (Surber et al., 2015).
Health care professionals must be educated to accurately assess skin conditions and make informed decisions about skin care interventions, and evidence-based pathways must be implemented. Studies are needed to develop evidence-based skin care regimens tailored to specific skin conditions to maintain skin integrity, especially in older adult populations, which are systematically underrepresented in clinical research.
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Demographic and Clinical Variables of Study Sample (N = 3,385)
|Variable||Males (n = 763)||Females (n = 2,622)|
|Age 60 to 84 (n = 414)||Age 85 and Older (n = 349)||Age 60 to 84 (n = 789)||Age 85 and Older (n = 1,833)|
|Age (years) (mean, SD)||76.9 (6.5)||90.4 (4)||78.4 (5.3)||91 (4.1)|
|Body mass index (kg/m2) (mean, SD)||26.3 (4.9)a||24.6 (3.9)b||26 (6)c||24.3 (4.8)d|
|Level of care dependency|
| 0||6 (1.4)||5 (1.4)||6 (0.8)||14 (0.8)|
| I||142 (34.3)||139 (39.8)||295 (37.4)||687 (37.5)|
| II||166 (40.1)||147 (42.1)||314 (39.8)||728 (39.7)|
| III/III+||78 (18.8)||50 (14.3)||142 (18)||334 (18.2)|
| Incontinence||272 (65.7)||225 (64.5)||533 (67.6)||1,243 (67.8)|
| Dementia||207 (50)||147 (42.1)||366 (46.4)||826 (45.1)|
| Diabetes||116 (28)||52 (14.9)||181 (22.9)||327 (17.8)|
|Activity (Braden scale)|
| Bedfast||51 (12.3)||30 (8.6)||100 (12.7)||176 (9.6)|
| Chairfast||123 (29.7)||82 (23.5)||234 (29.7)||480 (26.2)|
| Walks occasionally||71 (17.1)||99 (28.4)||154 (19.5)||480 (26.2)|
| Walks frequently||148 (35.7)||123 (35.2)||251 (31.8)||605 (33)|
|Mobility (Braden scale)|
| Completely immobile||47 (11.4)||23 (6.6)||89 (11.3)||172 (9.4)|
| Very limited||116 (28)||87 (24.9)||203 (25.7)||456 (24.9)|
| Slightly limited||123 (29.7)||136 (39)||249 (31.6)||689 (37.6)|
| No limitation||95 (22.9)||88 (25.2)||185 (23.4)||401 (21.9)|
|Residents who received at least one skin care application by nurses [95% CI]||337 (81.4) [77.4, 84.9]||308 (88.3) [84.5, 91.2]||665 (84.3) [81.6, 86.7]||1,670 (91.1) [89.7, 92.3]|
|Subgroup of residents with information about treated skin areas/body parts||270 (65.2)||122 (35)||503 (63.8)||822 (44.8)|
Frequencies of Treated Body Parts
|Age 60 to 84a||Age 85 and Olderb||Age 60 to 84c||Age 85 and Olderd|
|Body Part||n (%)||Body Part||n (%)||Body Part||n (%)||Body Part||n (%)|
|1||Full body||1,423 (37.7)||Full body||568 (32.7)||Full body||3,043 (40.2)||Full body||5,064 (39.8)|
|2||Buttock||436 (11.6)||Buttock||182 (10.5)||Face||1,143 (15.1)||Face||1,832 (14.4)|
|3||Face||409 (10.8)||Face||182 (10.5)||Buttock||704 (9.3)||Buttock||1,480 (11.6)|
|4||Legs||354 (9.4)||Legs||182 (10.5)||Upper body||527 (7)||Upper body||893 (7)|
|5||Upper body||233 (6.2)||Upper body||161 (9.3)||Legs||462 (6.1)||Lower body||640 (5)|
|6||Feet||181 (4.8)||Lower body||105 (6)||Lower body||413 (5.5)||Legs||585 (4.6)|
|7||Lower body||168 (4.5)||Back||84 (4.8)||Back||297 (3.9)||Back||497 (3.9)|
|8||Arms||165 (4.4)||Arms||77 (4.4)||Arms||262 (3.5)||Feet||471 (3.7)|
|9||Back||161 (4.3)||Feet||56 (3.2)||Feet||210 (2.8)||Genital area||455 (3.6)|
|10||Genital area||147 (3.9)||Genital area||42 (2.4)||Genital area||168 (2.2)||Arms||207 (1.6)|
|11||Scraped spots on head||14 (0.4)||Hands||35 (2)||Heels||56 (0.7)||Hands||168 (1.3)|
|12||Neck||14 (0.4)||Trunk||28 (1.6)||Trunk||56 (0.7)||Below breasts||77 (0.6)|
|13||Hands||14 (0.4)||Lower thighs||14 (0.8)||Hands||42 (0.6)||Heels||77 (0.6)|
|14||Lower thighs||14 (0.4)||Abdomen||7 (0.4)||Abdomen||35 (0.5)||Trunk||58 (0.5)|
|15||Trunk||8 (0.2)||Groin||7 (0.4)||Below breasts||28 (0.4)||Neck||42 (0.3)|
|—||Other||30 (0.8)||Other||7 (0.4)||Other||115 (1.5)||Other||168 (1.3)|