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Skin Barrier Break Downs: Risk Factors In The Geriatric Population

Skin Barrier Break Downs: Risk Factors In The Geriatric Population


Skin barrier dysfunction can precipitate various skin ailments in the elderly population, underscoring the importance of skin barrier assessment for nurses and caregivers in averting such conditions. Despite its significance, the clinical evidence on skin barrier assessment remains limited. To address this gap, a systematic review was conducted to elucidate the risk factors associated with skin barrier dysfunction in older adults.


Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search of four databases using pertinent terms related to aging and skin barrier was undertaken. The search, initiated on April 19, 2023, and repeated on October 12, 2023, targeted peer-reviewed quantitative studies in English without any temporal restrictions. Evaluation of bias risk was performed by two independent reviewers using JBI tools, ensuring a rigorous and unbiased approach. Due to the diversity in outcomes, a narrative synthesis was employed.


From the 4833 studies identified across databases, 20 met the inclusion criteria. The identified risk factors were classified into demographic characteristics, functional attributes, chronic ailments, nutritional status, skin condition, and environmental influences. Nonetheless, due to the prevalence of bias and inconsistent findings, only chronic kidney disease and dry skin emerged as significant risk factors for skin barrier dysfunction in older adults.


In conclusion, integrating the assessment of chronic kidney disease and dry skin into routine skincare practices holds promise for tailoring personalized skincare regimens to uphold skin integrity among older adults. Moreover, there is a pressing need for cohort studies that meticulously address confounding variables and ascertain measurement reliability to conduct a comprehensive exploration of skin barrier dysfunction and its associated risk factors.


Addressing the skin health of older adults emerges as a pivotal concern within nursing settings, particularly in today’s super-aged society. With the burgeoning population of older adults receiving long-term or home care, estimations suggest that by 2050, this demographic will more than double. Notably, skin aging is linked with various skin disorders, as evidenced by a comprehensive survey conducted in German nursing homes, which highlighted prevalent issues such as dry skin, incontinence-associated dermatitis, skin tears, and pressure ulcers.


Ensuring high-quality skin assessment and care becomes imperative to uphold skin integrity among older adults, despite the limited availability of reliable evidence. The skin barrier function, crucial for maintaining skin integrity irrespective of age, undergoes vulnerability in older adults due to both intrinsic and extrinsic age-related changes. Intrinsic aging leads to a slower turnover rate, epidermal thinning, and decreased levels of natural moisturizing factors, lipids, and sebum, resulting in compromised skin barrier function. 


Moreover, age-related health conditions, environmental factors, and improper skincare practices exacerbate skin barrier dysfunction risks. Therefore, it becomes paramount for nurses and caregivers to preemptively assess the risk of skin barrier dysfunction and adopt preventive skin care strategies. Such proactive measures not only mitigate the progression to severe skin disorders but also prove efficient in terms of reducing patient burden and associated costs.


Establishing a clinical assessment method gains significance given the indiscernible nature of skin barrier function and the requirement for costly instruments for its measurement. While existing reviews have outlined various factors associated with skin barrier dysfunction, particularly ethnicity, sex, skin type, lifestyle, and body mass index, a focused examination of evidence pertaining to older adults remains lacking.


Consequently, this systematic review endeavors to elucidate the risk factors linked with skin barrier dysfunction in older adults. By shedding light on these factors, the review aims to inform the development of effective skin assessment protocols and aid in the informed selection of appropriate skin care interventions for older adult populations.


The systematic review, conducted in adherence to the PRISMA 2020 guidelines and the JBI Reviewers’ Manual, commenced with a meticulously crafted review protocol registered in PROSPERO. This protocol served as a roadmap for the entire review process, ensuring transparency and accountability in research methodology.


To initiate the search for relevant literature, a comprehensive search strategy was formulated by the lead reviewer, informed by the review questions, keywords, and index terms pertinent to the study. This strategy underwent rigorous peer review by an experienced librarian and was finalized through consensus among all authors, thus ensuring its robustness and comprehensiveness.


The search was executed across multiple electronic databases, including MEDLINE, CINAHL, Cochrane Database of Systematic Reviews (CDSR), and Cochrane Central Register of Controlled Trials (CENTRAL). Notably, no publication time limit was imposed, underscoring the commitment to inclusivity and thoroughness in the review process.


Following the initial search, duplicate records were meticulously removed by the librarian using Microsoft Excel, minimizing redundancy and ensuring the integrity of the dataset.


The selection process, guided by detailed procedure manuals, involved screening titles and abstracts by two independent reviewers according to predefined eligibility criteria. Subsequently, a full-text screening of the remaining studies was conducted, with discrepancies resolved through consultation with a third reviewer. This investigator-blinded approach, facilitated by Rayyan software, minimized bias and ensured the robustness of study selection.


To augment the search for relevant literature, citation tracking of the remaining studies was performed, although no additional eligible studies were identified through this process.


Risk of bias assessment was conducted using appropriate tools, with the JBI critical appraisal tools employed for cross-sectional studies and randomized controlled trials (RCTs). Discrepancies in assessment were resolved through consensus, and results were visualized using the robvis tool, enhancing transparency and reproducibility.


Data extraction encompassed a comprehensive range of parameters, including author details, publication years, study design, participant characteristics, outcomes, and funding sources. This process, carried out independently by two reviewers and cross-checked by all members, ensured accuracy and completeness of data extraction.


Given the heterogeneity of results, meta-analysis, reporting bias assessment, and certainty of evidence proved challenging, necessitating a narrative synthesis approach.


Importantly, the review focused solely on extracting risk factors, excluding protective factors, in alignment with the study objectives. Factors were meticulously categorized and ranked based on statistical significance, agreement across studies, and risk of bias, thereby ensuring a rigorous and systematic approach to data synthesis.


Overall, the systematic review adhered to rigorous methodological standards, encompassing comprehensive search strategies, robust selection processes, rigorous risk of bias assessment, and meticulous data extraction and synthesis, thereby contributing valuable insights to the field of inquiry.

Inclusion Criteria

The review aimed to identify the risk factors linked to skin barrier dysfunction among older adults, focusing on demographic and health characteristics relevant to skin assessment, rather than interventions. Specifically, it concentrated on studies addressing risk factors associated with skin barrier dysfunction, excluding those that did not. The review prioritized Transepidermal Water Loss (TEWL) and Stratum Corneum Hydration (SCH) as outcome measures, aligning with established international guidelines. Elevated TEWL or reduced SCH are indicative of skin barrier dysfunction according to these guidelines. The literature search employed inclusion and exclusion criteria based on population, exposure, and outcome parameters to ensure relevance and rigor in the selection process.


The systematic review initially identified a large pool of studies from various databases. Through a rigorous screening process, duplicates and studies not meeting eligibility criteria were excluded, resulting in a refined selection of 20 studies for detailed analysis. This process ensured that only relevant and high-quality studies were included in the review.


Characteristics of Included Studies:

The 20 studies included in the review were predominantly cross-sectional, with one randomized controlled trial (RCT). They were conducted across different regions such as Japan, China, Germany, Israel, the United States, Netherlands, and India, covering diverse settings including controlled environments, hospitals, long-term care facilities, and community settings. The sample sizes varied, ranging from 40 to 713 participants, providing a broad representation of older adults in various contexts.


Assessment of Skin Barrier Function:

Stratum corneum hydration (SCH) and transepidermal water loss (TEWL) were the primary measures of skin barrier function evaluated across the studies. Various instruments were utilized to assess these parameters, reflecting the diversity of methodologies employed in skin barrier research. Notably, different studies utilized different instruments, potentially introducing variability in the results.


Risk of Bias Assessment:

A critical aspect of the review involved assessing the risk of bias in the included studies. This evaluation revealed varying levels of bias across studies, with many failing to adequately address confounding factors or provide reliable measures of skin barrier function. These findings underscore the importance of interpreting the results with caution and considering the methodological limitations of individual studies.


Identification of Risk Factors:

The review identified several factors associated with skin barrier dysfunction in older adults. These factors encompassed demographic characteristics, functional impairments, chronic diseases, nutritional status, skin conditions, and environmental influences. For example, chronic kidney disease (CKD), diabetes/dyslipidemia, dry skin, and certain environmental factors emerged as significant risk factors, while the association of other factors such as sex, ethnicity, and nutritional status showed varying degrees of evidence across studies.


Synthesis of Findings:

To provide a comprehensive overview, the review synthesized the findings into different levels of evidence based on the strength of association and consistency across studies. This categorization helps prioritize significant risk factors while acknowledging the uncertainty surrounding others. Overall, the synthesis highlights the multifactorial nature of skin barrier dysfunction in older adults and emphasizes the need for further research to elucidate underlying mechanisms and develop targeted interventions.


Expanding on these sections provides a more detailed insight into the systematic review’s methodology, findings, and implications for understanding skin barrier dysfunction in older adults.


In a comprehensive systematic review focusing on identifying risk factors for skin barrier dysfunction in older adults, it was observed that 13 out of 20 studies exhibited a moderate to high risk of bias, mainly due to inadequate handling of confounding factors. Since all data were derived from cross-sectional analyses, establishing causal relationships between identified factors and skin barrier function was not feasible. Consequently, results were narratively synthesized considering bias and result inconsistency.


The review highlighted chronic kidney disease (CKD) and dry skin as notable risk factors for skin barrier dysfunction in older adults. While other reviews have suggested associations between skin barrier function and various factors like ethnicity, sex, and lifestyle across different age groups, this study specifically focused on older adults, thus revealing unique risk factors within this demographic.


Globally, CKD has emerged as a significant health concern among the elderly population, affecting a considerable percentage in the United States. The vulnerability of the skin barrier in CKD patients is attributed to metabolic imbalances, endocrine disorders, and peripheral neuropathy. However, the influence of different CKD stages on skin barrier dysfunction requires further investigation.


Dry skin, characterized by a deficiency in hydrolipids, is closely linked to skin barrier dysfunction. Its prevalence among older adults across clinical settings underscores the importance of clinical assessment for effective skin care.


Despite identifying potential risk factors, the review underscores the need for further research due to the low quality of evidence, primarily stemming from methodological shortcomings in existing studies. Factors like purpura, edema, certain diseases, and medications were not fully addressed, warranting additional investigation.


To enhance future research, the review recommends recognizing and addressing confounding factors, ensuring reliability of measurements, and conducting higher-quality cohort studies. Such endeavors can provide valuable insights into the association between various factors and skin barrier function in older adults.


In conclusion, the review’s findings emphasize the significance of evaluating CKD and dry skin in older adults to tailor effective skin care interventions. By implementing appropriate assessment tools and considering confounding factors, healthcare professionals can develop personalized skin-care programs to address skin barrier dysfunction in this demographic.

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