14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture

1. Venous Ulcers and Chronic Wounds

Venous ulcers account for the large majority of leg ulcers. They occur in the gaiter area, classically over the medial malleolus, are shallow with irregular borders and exudate, and sit in skin showing hemosiderin staining, lipodermatosclerosis, atrophie blanche and varicosities. Pain improves with elevation.

Treatment rests on three pillars:

1. Compression therapy — multilayer compression is the single most effective intervention and the strongest determinant of healing
2. Leg elevation and calf muscle pump exercise
3. Moist wound care with appropriate dressings

Before compression, measure the ankle-brachial index. Applying full compression to a limb with significant arterial disease causes ischemic necrosis. This is the highest-yield safety point in wound care.

Recurrence is the rule without lifelong compression stockings; endovenous ablation of incompetent superficial veins reduces recurrence.

Diabetic (neuropathic) foot ulcers occur at plantar pressure points, are surrounded by callus, and are painless. The essential treatment is offloading, together with glycemic control, debridement, infection management and vascular assessment. Common foot problems in the elderly — an enumerated blueprint subsection — include onychomycosis, ingrown nails, hallux valgus, hammer toes, corns and calluses; in a person with neuropathy or vascular disease these are not cosmetic issues but the origin of limb-threatening ulceration, which is why annual foot examination and appropriate footwear matter.

An ulcer that fails to heal after several months of appropriate therapy should be biopsied to exclude malignancy (Marjolin ulcer) or an inflammatory cause such as pyoderma gangrenosum.

2. Nutrition in the Elderly

Weight loss in an older adult is never benign. Unintentional loss of 5% of body weight over 6 to 12 months warrants evaluation.

A structured differential:

Ask specifically about who buys and prepares the food. Social and functional causes are common and invisible unless asked about directly.

Sarcopenia — loss of muscle mass, strength and function — is treated with resistance exercise plus adequate protein intake, generally higher than in younger adults. Appetite stimulants have limited evidence and meaningful harms: megestrol increases thromboembolism and adrenal suppression, and mirtazapine is reasonable when depression coexists.

Deficiencies to consider: vitamin B12 (common with atrophic gastritis and metformin), vitamin D, calcium, and protein-energy undernutrition.

3. Disorders of Swallowing

The first distinction is oropharyngeal versus esophageal, because it determines both the test and the specialist.

Solids only, progressive suggests a mechanical obstruction; solids and liquids from the outset suggests a motility disorder.

Aspiration risk is highest with oropharyngeal dysphagia, and silent aspiration without cough occurs in patients with reduced laryngeal sensation, especially after stroke. Management includes texture modification, postural techniques, swallowing therapy and rigorous oral hygiene, which independently reduces aspiration pneumonia.

Feeding tubes in advanced dementia are the highest-yield exam point in this area: percutaneous gastrostomy does not reduce aspiration, does not improve survival, does not heal or prevent pressure injuries, and does not improve comfort or function. It increases the use of restraints and the burden of tube-related complications. Careful hand feeding is the recommended alternative, and this discussion belongs in goals-of-care conversations early rather than at a crisis point.

4. Constipation in the Elderly

A named blueprint subsection, and a source of substantial morbidity — fecal impaction with overflow diarrhea, urinary retention, delirium and stercoral ulceration.

Contributors: reduced mobility and fluid intake, low fiber, medications (opioids, anticholinergics, calcium channel blockers, iron, calcium, antipsychotics), hypothyroidism, hypercalcemia, hypokalemia, diabetes, Parkinson disease, and colorectal obstruction.

Red flags requiring colonoscopy: new-onset constipation in an older adult, rectal bleeding, iron deficiency anemia, weight loss, or a family history of colorectal cancer.

Management ladder: address reversible causes and deprescribe; increase fluid, fiber and activity as tolerated; osmotic laxatives such as polyethylene glycol are first-line pharmacotherapy; stimulants as needed. Fiber supplementation can worsen symptoms in slow-transit constipation and in patients with limited fluid intake or obstruction.

Opioid-induced constipation does not develop tolerance and must be anticipated: prescribe a bowel regimen with every opioid, and use peripherally acting mu-opioid receptor antagonists when standard laxatives fail.

Always examine for fecal impaction when an older adult has overflow diarrhea, delirium or urinary retention; treating the diarrhea as infectious is a classic error.

5. Hip Fracture

A named blueprint subsection, and one of the defining events of later life: roughly a fifth to a quarter of older adults die within a year of hip fracture, and many survivors never regain prior function.

Classification determines the operation:

Perioperative principles supported by evidence:

• Surgery within 24 to 48 hours reduces mortality, delirium, pressure injury and pneumonia. Medical optimization should not become an open-ended delay.
• Orthogeriatric co-management improves outcomes.
• Regional or general anesthesia are broadly comparable; avoid meperidine and minimize benzodiazepines and anticholinergics to reduce delirium.
• Multimodal analgesia including nerve blocks reduces opioid requirements and delirium. Under-treated pain is itself a delirium risk factor, so opioid avoidance can backfire.
• Early mobilization, ideally on the first postoperative day.
• Venous thromboembolism prophylaxis.
• Delirium prevention protocols.

The secondary prevention gap is the most tested point. A hip fracture from a fall from standing height is an osteoporotic fracture and establishes the diagnosis of osteoporosis regardless of bone density. Yet a majority of patients leave the hospital without osteoporosis treatment. Before discharge: check vitamin D and calcium, correct deficiency, initiate antiresorptive or anabolic therapy, review fall risk and deprescribe culprit medications, and arrange rehabilitation.

6. Rehabilitation and the Elderly

A named blueprint subsection. The internist decides the level of post-acute care, which materially affects outcomes.

Prognostic factors: pre-morbid functional status is the strongest predictor of recovery; cognitive impairment, depression, malnutrition, delirium and inadequate social support all impair rehabilitation potential. Depression and delirium are treatable barriers and should be sought and addressed rather than accepted as reduced potential.

Immobility itself causes harm — deconditioning of roughly 1 to 5% of muscle strength per day of bed rest, pressure injury, venous thromboembolism, atelectasis, constipation, orthostatic intolerance and delirium. Hospital-associated disability — new functional loss occurring during an admission independent of the presenting illness — is common, frequently permanent, and largely preventable by mobilizing patients and avoiding unnecessary tethers such as urinary catheters, telemetry and continuous infusions.

7. Urinary Tract Infection in the Elderly

A named Geriatric Syndromes subsection, and the source of one of the most consequential errors in geriatric medicine.

Asymptomatic bacteriuria is common in older adults — highly prevalent in nursing home residents and near-universal in those with chronic catheters — and should not be screened for or treated, with the exceptions of pregnancy and before urologic procedures with anticipated mucosal bleeding.

A positive urine culture does not diagnose a urinary tract infection. Diagnosis requires localizing genitourinary symptoms — dysuria, new urgency or frequency, suprapubic or costovertebral angle pain, gross hematuria — or systemic features attributable to the urinary tract.

The delirium trap: an older adult with delirium and a positive urine culture very often has delirium from another cause — a new medication, dehydration, constipation, pain, hypoxia — with incidental bacteriuria. Reflexively attributing delirium to a urinary tract infection stops the search for the real cause and exposes the patient to antibiotic harm, Clostridioides difficile infection and resistance. Look for another cause even after starting antibiotics.

Recurrent infection in postmenopausal women is reduced by vaginal estrogen, which is preferable to long-term antibiotic prophylaxis.