THE SKIN

The changes in the skin are a cause of angst (=a feeling of anxiety and worry
about a situation, or about your life) as they are amongst the most obvious signs
of ageing, and people go to great lengths to try to hold back the process.
But there are other physiological reasons why age-related changes in the skin
are important.

Pressure sores (also known as bed sores or pressure ulcers) are a significant
problem in the aged, and dermatological diseases affect many people as they
get older.
The skin is our protection from the environment, and changes in the skin alter
our ability to respond to changes in the world around us.

The functions of the skin

The primary function of the skin is to separate the cells of the body from the
external environment - the skin is playing a fundamental role in homoeostasis
and defence which are fundamental to our survival.

External threats to our well being come in many forms.

One of the greatest threats is change in the water content in the environment.
Our cells need to have a watery environment in which to function.
However, the atmosphere is relatively dry.
Without the skin, we would rapidly dehydrate.
On the other hand, in a watery environment, our cells body would take up
excessive amounts of water.
The skin helps to maintain the appropriate level of hydration.

Other threats to our body which the skin helps to combat include radiation
from the sun, and environmental pathogens.
The skin is impermeable to many chemicals which could otherwise enter the
body and damage the tissues.
Inevitably, the constant exposure of the skin to threats, particularly from solar
radiation, results in damage which is often irreversible.
The structure of the skin

The general structure of the skin can be divided into three parts: the epidermis,
the dermis and the connective tissue.

1. The epidermis

The epidermis is the outer layer of the skin and is in full contact with the
environment.
It is made up of several layers of cells which are filled with keratin, a tough
protein which gives the epidermis its strength.
As the keratin containing cells move from deeper layers to the surface of the
skin, they die and are eventually shed (=if an animal sheds its skin, it loses them
naturally) from the surface of the skin.
The reason that the cells die as they move to the surface is that they are starved
of oxygen and nutrients - the epidermis has no blood or nerve supply.
Oxygen and nutrients are delivered from the underlying dermis.

The epidermis contains the melanocytes, which produce the pigment (=a
substance that exists naturally in people, animals and plants and gives their skin,
leaves, etc. a particular colour) melanin.
Melanin is responsible for darkening the skin (the pink colour of the skin is due
to blood flow through the capillaries (=any of the smallest tubes in the body
that carry blood) in the dermis).

A third type of cell found in the epidermis is the Langerhans cell.

These cells have an immunological function, and help to protect the skin against
infection.

2. The dermis

The dermis is located underneath the epidermis.

It contains large amounts of collagen and elastin together with blood vessels
and nerves.
The collagen and elastin create tensile strength (=used to describe the extent to
which something can stretch without breaking) and elasticity in the tissue, and
are responsible for much of the stretch found in normal skin.

The epidermis and dermis are strongly attached to each other by

interdigitations (or folds).
In other words, folds of dermis project into the epidermal structure, locking the
two together like the teeth of a zipper.

The dermis is also the location of the sweat and sebaceous glands.
The sebaceous glands are responsible for producing the oils which keep the skin
moist.

Associated with the nerve endings in the dermis are the specialised receptors
which convert stimuli such as vibration and temperature into action potentials
in nerves.
The action potentials convey the information from the receptors to the central
nervous system.

There is also a loss of cells in the dermis.

The loss of dermal cells increases the fragility of the skin (remember that
collagen and elastin provided tensile strength and elasticity.

It has been estimated that rate of dermal collagen loss is approximately 1% per
year.
The structure of collagen is an important contributor to its functional capacity.
With ageing, the normal arrangement is lost and the collagen becomes thicker
and stiffer.
The loss of elastin is responsible for wrinkling.
The thin, almost translucent skin which is characteristic of the aged is primarily
the result of the atrophy of the dermis.

The skin of the aged is fragile due to the loss of collagen.

Wrinkling is due to the loss of elastin.
The connection between the epidermal and dermal layers is significantly
weakened.
This means that minor tearing forces, which have no effect on younger people
can result in significant damage in the aged.
This comes on top of the thinning of the epidermal and dermal layers which
decreases the protection for the dermal blood vessels, and increases the risk of
injury.

The loss of cells in the dermis is generalised, so the number of sweat and
sebaceous glands, and the number of nerve endings also decreases.
The loss of glands means that the skin becomes drier.

The sense of touch and vibration decreases.

This may have serious consequences, as it limits the ability of the aged to
quickly detect noxious (=poisonous or harmful) stimuli.
If the stimuli aren't detected, the protective reflexes will not be initiated.
Consequently, serious injuries such as burns are more likely to occur.
This may be addressed by providing visual cues (=an action or event that is a
signal for somebody to do something) for the presence of potentially dangerous
conditions, such as clear lighting to indicate when ovens are on.

The ability of the skin to detect noxious stimuli is decreased.

Changes in the blood vessels in the dermis also occur.

There is a general decrease in the blood flow which results in the skin of the
aged feeling colder than that of younger people.
Another effect of the decrease in blood flow is to slow the growth of the finger
and toe nails.
More importantly, the decreased blood flow to the skin limits the delivery of
heat.
If heat is not delivered to the skin, it can't be lost from the body.
The changes in dermal blood flow can have a significant effect on
thermoregulation.
In addition, it appears that the vessel walls become weaker, increasing the
susceptibility to bruising.
The main change which occurs in ageing subcutaneous tissue is a loss of fat.
This can be very significant, as it reduces the padding of the tissue and increases
the risk of pressure sores developing.
Another function of the fat is to generate the normal contours of the body, so
the loss of fat can be a major contributor to wrinkling and sagging.

Pressure sores and wound healing

Pressure sores are a major problem in the aged, not just because of the sore
itself, but with the complications which often arise, and which can frequently be
fatal.
Although pressure sores initially involve only the skin, they can spread into
deeper tissues.

Pressure sores can be caused in two ways.

The first is direct pressure, which may be experienced by someone confined
(=to have to stay in bed, in a wheelchair, etc.) to bed.
When the pressure on the skin is high enough, it will stop blood flow through
the tissue.
The loss of blood flow will result in tissue death, and the signs of a pressure
sore will begin to develop in a few hours.
The second cause of a pressure sore is shearing force exerted on the skin by a
sliding movement.

Some groups of people are at increased risk of developing pressure sores.

These include those suffering from malnutrition, and urinary or faecal
incontinence.
People with foot pain may alter their gait (=a way of walking), increasing the
pressure on different parts of the foot resulting in ulcer development.
Another at risk group are those who have a decreased sense of touch.
Newly admitted nursing home patients were the most likely to develop pressure
sores, probably because of their generally poor physical condition.

Ulcers (=an open sore on an external or internal surface of the body, caused by
a break in the skin or mucous membrane which fails to heal) may also be caused
by circulatory insufficiency and diabetes mellitus.
Often diabetes initially causes itching without a rash.
If people in your care suffer itching with no rash present, you should ensure that
they seek medical advice (another cause of this problem is a tumour).

The process of wound healing is slowed in the aged.

Weksler (1998) lists the following as contributing to the slowing of healing:
systemic disease especially diabetes and vascular disease
medications (especially corticosteroids)
poor nutrition
smoking
circulatory insufficiency (evident as swelling and discolouration, particularly of
the legs).

Pressure sores are graded to four levels, including:

grade I skin discolouration, usually red, blue, purple or black
grade II some skin loss or damage involving the top-most skin layers
grade III necrosis (death) or damage to the skin patch (=a small area of
something, especially one which is different from the area around it),
limited to the skin layers
grade IV necrosis (death) or damage to the skin patch and underlying
structures, such as tendon, joint or bone.

Complications of pressure sores

Untreated pressure sores can lead to a wide variety of secondary conditions,
including:
sepsis (bacteria entering the bloodstream);
cellulitis (inflammation of body tissue, causing swelling and redness);
bone and joint infections;
abscess (a collection of pus).

People who use a wheelchair are most likely to develop a pressure sore on the
parts of the body where they rest against the chair.
These may include the tailbone or buttocks, shoulder blades, spine and the backs
of arms or legs.
When a person is bedridden, pressure sores can occur in a number of areas,
including:
back or sides of the head;
rims of the ears;
shoulders or shoulder blades;
hipbones;
lower back or tailbone;
backs or sides of the knees;
heels, ankles and toes.

What are age-related changes that occur in the skin and how do they relate to
changes in function and skin related problems in the aged?

As would be expected, there is a general decrease in the function of all the

structures of the skin.
In the epidermis, the outer layer of the skin, the melanocytes and Langerhans
cells become less functional result in the skin becoming more pale, and less able
to resist infection.
In the dermis there is a decrease in collagen levels resulting in a loss of strength,
and a decrease in elastin resulting in decreased elasticity.
There are fewer sweat and oil glands so the skin becomes drier.
In the hypodermis there is less fat meaning that the skin is less padded from
underlying structures and therefore more susceptible to pressure sores.

How do changes in body systems affect the skin?

Changes in immune function can increase the risk of infection occurring,

complicating the loss of strength that occurs normally in the ageing skin.
Changes in the cardiovascular system can also affect skin health and immune
function.
Various diseases affecting different body systems can also have an adverse
effect on the skin.