Our observational study shows the existence of an association between frailty and wound healing. Since one of the main goals of wound clinical units is to shorten healing time, the incorporation of frailty assessment is a tool that might be introduced in their daily practice for helping in the wound management in elderly patients.
Our sample consisted of frail, elderly patients with multimorbidity. Despite the fact that all of them are residents in the community and a non-negligible percentage were living alone (4/10), the sample presents some indicators of disability for carrying out basic everyday activities, and most of them required help with at least one of the instrumental activities of daily living, implying a greater functional impact than results reported in the literature for populations of similar characteristics [27]. A low percentage of patients was diagnosed with dementia (12%) prior to their inclusion in the study. This figure differs greatly from the results obtained in cognitive ability tests, which suggested underdiagnosis of cognitive impairment, in accordance with previously published results [33]. Malnutrition is a well-known factor that negatively influences wound healing [34, 35]. In our case, its presence was of little relevance as a low number of malnourished patients and patients at risk of malnutrition was identified. So, we can state that mal- and undernutrition were not a determining factor in wound healing for our group of patients. This may be because the association of malnutrition and tissue repair has not been homogeneous between different wound etiologies and this correlations is strong in pressure ulcers which are underrepresented in our patients sample [36, 37]. All this clinical data corroborates that for the patients in this cohort, geriatric assessment detects deficits in several domains highlighting a health vulnerability that goes beyond the wound. In line with previous studies, our data confirms that elderly patients with wounds require a significant degree of healthcare [38].
In the last decade, frailty instruments have been introduced to the regular clinical practice as support for clinicians to achieve better decision-making. Frailty tools had been used to characterize a population, yielding a risk stratification, and having identified patients at greater risk of adverse health outcomes, then is the time to initiate a process of shared decision-making which should end with individualized care planning [15, 39–41].
Three-quarters of the patients treated at the MWCC present with frailty. The way patients are identified as being frail, whether through the Frail-VIG index, the SHARE-FI test or physical performance tests such as gait speed, hardly affects their classification, as confirmed by other authors [42, 43]. This figure contrasts with the frailty detected in the community-dwelling population aged > 70 years, where Rivas-Ruiz et al. reported 26% of frailty in community-dwelling elderly persons in Spain using a phenotype tool [44]. Another systematic review, conducted by Collard et al., identifies a very variable spectrum of frailty in community-dwelling older people that ranges from 4.9–59.1% [45]. This large difference in the identification of frailty is most likely related to the fact that patients with chronic wounds have a high multimorbidity load, some degree of disability, and a high prevalence of mild cognitive impairment.
When comparing the results of the two instruments, (Frail-VIG and SHARE-FI), we observe that both instruments are able to characterize the population appropriately. By verifying that they classify patients in a similar way, we have chosen to evaluate patients using the Frail-VIG index as it enables rapid geriatric assessment and the detection of areas of intervention [22].
As the frailty score did not reveal any statistically significant differences during patient follow-up, it suggests that frailty evaluation could be performed at any time of the wound care process, unless clinically relevant issues emerge. Based on our data, we propose frailty assessment at any point of wound follow-up, especially in the event of healing delay or absence of healing. Being aware of patient frailty will help to better understand patients’ global health, which could be an aid to decision-making in order to modify their individualized treatment plan, if necessary.
Our data identifies an association between the degree of frailty and wound healing, both evaluated from the variable ‘healing/not healing’ and in relation to the variable ‘healing rate’. Our results suggest that determining the healing rate parameter might prove highly useful for the early prediction of delayed wound healing, which could also help clinicians in their decision-making and adjust the appropriate therapeutic approach.
Wound healing is related to multiple factors. On the one hand, we have the widely-known and much studied local factors, and on the other hand, we have systemic factors [9, 46]. Frailty acts as a systemic factor in wound healing. This idea is strengthened by the observation of different behavior in relation to frailty between wounds of venous etiology and others. This data is in accordance with the fact that local factors have a major impact on venous ulcers and they are less influenced by a systemic issue as degree of frailty [9, 46]. In contrast, in wounds of other etiologies (arterial, DM2, etc.), the degree of frailty correlates very well with wound healing capacity, which makes sense because such wound etiologies correlate with systemic diseases [47]. Our data confirms the frame of frailty, describing that frailer patients tend to have poorer health outcomes.
In accordance with other medical and surgical areas in which the assessment of frailty is used to identify patients prone to poor health outcomes [48, 49], our results suggest that establishing frailty may prove useful for wound healing management according to the relation of frailty with healing delay and/or absence of healing. A greater number of advanced therapeutic strategies are available for the treatment of non-healing wounds. However, the effectiveness of these new therapies is not clear. Our results show that a frailty index is a good prognostic indicator of wound healing that could be used for clinical decision-making to improve treatment, not only according to local wound factors, but also patients’ global health status [50]. This study demonstrates that establishing healing rate may also have a prognostic value, in line with data from previous studies [51].
MWCC are usually integrated by a multidisciplinary team that allows not only wound care treatment based on wound etiology but also according to patients’ global needs. Our results suggested that because of the high prevalence of frailty in patients treated at our MWCC, it would be useful to include the measurement of frailty as part of the regular assessment of patients in wound units. This data would be useful for more personalized clinical decision-making in this group of elderly patients.
Consideration and evaluation of frailty are extremely important components in caring for the growing number of elderly patients with complex wounds. While the study of frailty in relationship to wound healing is in its infancy, our results reveal that there is enough data to begin to unravel the complexities associated with caring for frail elderly individuals with complex wounds. Further research is needed both to improve our understanding and our treatment strategies for this particularly frail and at-risk population. Our study has some limitations, we have a low number of participants, because only those patients who could be assured of follow-up for the next 6 months were included. Additionally, our study allows to demonstrate an association between the presence of frailty and wound healing, however in any case it had been established a causal relationship. Our data suggests that classification according to different degrees of frailty could help in wound management. In our opinion, patients with severe frailty and non-healing wounds could benefit from a palliative approach, however, patients with moderate/mild frailty might be candidates for advanced wound therapies.