Geriatric considerations - Integumentary: Nursing

Geriatrics is the branch of medicine that deals with the physiology and psychology of aging, as well as the diagnosis and treatment of diseases affecting older clients. Now, aging affects various organ systems, one of which is the skin, also known as the integumentary system.

Alright, now let's start by reviewing the physiology of the integumentary system, which is the outer barrier that protects the body from excessive water loss, as well as any external threat like trauma or pathogens. The skin is divided into three main layers, the hypodermis, dermis, and epidermis. The hypodermis, also known as the subcutaneous layer of the skin, is made of fat and connective tissue that anchors the skin to the underlying muscle, and acts as a cushion that protects underlying tissues from trauma. Above the hypodermis is the dermis, containing collagen and elastin fibers, nerve endings, sweat and sebaceous glands, as well as blood and lymphatic vessels. Just above the dermis is the epidermis, which has multiple cell layers that are composed of developing cells called keratinocytes, which are flat pancake-shaped cells that are named for the keratin protein that they’re filled with.

Keratinocytes start their life at the basal layer, also called the stratum basale, which is made of a single layer of stem cells that continually divide and produce new keratinocytes. This layer also contains the melanocytes, which produce a pigment called melanin, that gives each individual their skin color, and acts as a natural sunscreen. Now, as keratinocytes mature, they migrate into the next layers of the epidermis, called the stratum spinosum, and then into the stratum granulosum. Keratinocytes in this layer begin the process of keratinization, which is the process where the keratinocytes flatten out and die, and in the process they begin to create the epidermal skin barrier.

Keratinization leads to development of the stratum lucidum layer which is made up of translucent, dead keratinocytes. The stratum lucidum is only found in thick skin like on the palms of the hands and soles of the feet, because those are the areas that need extra protection. Finally, there’s the stratum corneum, or the uppermost and thickest layer of the epidermis. As new keratinocytes push up into the stratum corneum, older dead cells are sloughed off forming skin flakes.

Now, the skin also houses appendages, which include hair, sebaceous and sweat glands, and nails. Each hair consists of a hair follicle, which lies in the dermis, and a hair shaft, which spans the epidermis reaching the surface of the skin. Sebaceous glands lie in the dermis and release sebum into the hair follicles. Sweat glands also lie in the dermis, and release sweat that may flow to the hair follicle or directly into the skin surface. Finally, nails are extensions of the epidermis that protect and enhance sensations of the tips of the fingers and toes.

Okay, let’s look at some of the effects of aging on the integumentary system. First, subcutaneous fat is lost from the hypodermis during the aging process. This decreased padding increases the risk for hypothermia, because there’s less insulation. Decreased subcutaneous tissue also increases risk of pressure injuries on certain pressure points around the body, like the buttocks and hips. Moreover, the absorption of topical medication administered to a geriatric client can change due to decreasing subcutaneous tissue.

In the dermis, there’s decreased thickness, along with degeneration of elastin fibers, stiffening of collagen fibers, and decreased vascularity. These changes result in increased wrinkling and sagging of the skin. Increased fragility and permeability of capillaries can be noted, which results in easy bruising. The number and function of sweat glands decreases, so there’s less body odor, but also a reduced ability for the body to cool by evaporative heat loss, increasing the risk of heat stroke. Decreased sebaceous gland activity leads to drier, flaking skin. And nerve endings also decrease in number, resulting in diminished awareness of sensations, including pain, touch, pressure, and temperature. In addition, nails grow more slowly with age, and they become thicker, more brittle.

Age-related thinning of the epidermis results in decreased barrier protection, decreased ability of the skin to repair itself when damaged. Damage occurs more easily too, and due to a decreased adherence between the epidermis and dermis, skin tears can easily occur when moving a geriatric client or pulling them up in bed.