Assessment and Management of Pressure Ulcers in the Elderly
Pressure ulcers (pressure sores) continue to be a common health problem, particularly among the physically limited or bedridden elderly. The problem exists within the entire health framework, including hospitals, clinics, long-term care facilities and private homes.
For many elderly patients, pressure ulcers may become chronic for no apparent reason and remain so for prolonged periods, even for the remainder of the patient’s lifetime. A large number of grade 3 and 4 pressure ulcers become chronic wounds, and the afflicted patient may even die from an ulcer complication (sepsis or osteomyelitis).
The presence of a pressure ulcer constitutes a geriatric syndrome consisting of multifactorial pathological conditions. The accumulated effects of impairment due to immobility, nutritional deficiency and chronic diseases involving multiple systems predispose the aging skin of the elderly person to increasing vulnerability.
The assessment and management of a pressure ulcer requires a comprehensive and multidisciplinary approach in order to understand the patient with the ulcer. Factors to consider include the patient’s underlying pathologies (such as obstructive lung disease or peripheral vascular disease), severity of his or her primary illness (such as an infection or hip fracture), co-morbidities (such as dementia or diabetes mellitus), functional state (activities of daily living), nutritional status (swallowing difficulties), and degree of social and emotional support; focusing on just the wound itself is not enough. An understanding of the physiological and pathological processes of aging skin throws light on the aetiology and pathogenesis of the development of pressure ulcers in the elderly.
Each health discipline (nursing staff, aides, physician, dietitian, occupational and physical therapists, and social worker) has its own role to play in the assessment and management of the patient with a pressure ulcer. The goals of treating a pressure ulcer include avoiding any preventable contributing circumstances, such as immobilization after a hip fracture or acute infection. Once a pressure ulcer has developed, however, the goal is to heal it by optimizing regional blood flow (by use of a stent or vascular bypass surgery), managing underlying illnesses (such as diabetes, hypothyroidism or congestive heart failure) and providing adequate caloric and protein intake (whether through use of dietary supplements by mouth or by use of tube feeding). If the ulcer has become chronic, the ultimate goal changes from healing the wound to controlling symptoms (such as foul odour, pain, discomfort and infection) and preventing complications, thereby contributing to the patient’s overall well-being; providing support for the patient’s family is also important. Recent advances in wound dressings allow for greater control of symptoms and prevention of complications, and have also enabled the affected patient to be integrated more readily into the family setting and in the community at large. Ethical and end-of-life issues must also be addressed soon after the wound has become chronic.
This article discusses the pathogenesis of pressure ulcer development in the elderly in relation to concomitant diseases, risk factor assessment and the management of such ulcers.
No sources of funding were used to assist in the preparation of this review. The author has no conflicts of interest that are directly relevant to the content of this review. The author would like to thank Dr Sheva Mann, Professor Arnold Rosin and Iris Arad for their help in editing the article.
- 4.Smith DM. Pressure ulcers. In: Besdine RW, Rubinstein LZ, Sznder L, editors. The medical care of the nursing home resident. Philadelphia (PA): American College of Physician, 1996: 61–74Google Scholar
- 28.Doughty D. The process of wound healing: a nursing perspective. Prog Develop Ostomy Wound Care 1990; 2: 3–12Google Scholar
- 36.Stadelmann WK, Digenis AG, Tobin GR. Impediments to wound healing. Am J Surg 1998; 176: 36–47Google Scholar
- 41.Norton D, McLaren R, Exton-Smith AN. An investigation of geriatric nursing problems in hospital. London: Churchill Livingstone, 1962: 193–224Google Scholar
- 46.Pinchcofsky-Devin GD, Kaminiski NW. Correlation of pressure sores and nutritional status. J Am Geriatric 1986; 34: 435–40Google Scholar
- 50.Mintzer J, Burns A. Anti-cholinergic side effect of drugs in elderly people. J R Soc 2000; 93: 457–62Google Scholar
- 64.Reswick JB, Rogers J. Experience at Rancho los Amigos Hospital with devices and techniques to prevent pressure sores. In: Kennedi RM, Cowden JM, Scales JT, editors. Bedsore biomechanics. Baltimore (MD): University Park Press, 1976: 301–13Google Scholar
- 65.Bennet L, Kavner D, Lee BY, et al. Skin blood flow in seated geriatric patients. Arch Phys Med Rehabil 1981; 62: 392–8Google Scholar
- 72.Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in the elderly. Cochrane Database Syst Rev 2005; (2): CD001880Google Scholar
- 73.Langer G, Schloemer G, Knerr A, et al. Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database Syst Rev 2003; (4): CD003216Google Scholar
- 83.Bale S. A guide to wound debridement. J Wound Care 1997; 4: 179–82Google Scholar
- 85.Moore D. Hypochlorites: a review of the evidence. J Wound Care 1992; 1(4): 44–53Google Scholar
- 86.Thomas S, Loveless P. A comparative study of the properties of twelve hydrocolloid dressings. World Wide Wounds 1997 July [online]. Available from URL: http://www.worldwidewounds.com/1997/july/Thomas-Hydronet/hydronet.html [Accessed 2010 Jan 19]Google Scholar
- 87.Belmin J, Meaume S, Rabus MT, et al. Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus non sequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc 2002; 50(2): 269–74PubMedCrossRefGoogle Scholar
- 98.Kranke P, Bennett M, Roeckl-Wiedmann I, et al. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev 2004; (2): CD004123Google Scholar
- 99.Baba-Akbari Sari A, Flemming K, Cullum NA, et al. Therapeutic ultrasound for pressure ulcers. Cochrane Database Syst Rev 2006 Jul 19; (3): CD001275Google Scholar