BMH Medical Journal

BMH Med. J. 2020; 7(Suppl): Early Online. Geriatrics & Gerontology Initiative: International Workshop on Care of the Elderly

Abstract

Bed sores are not uncommon in the elderly, since it affects people who spend a long time in one position without shifting of body weight. Quite obviously the elderly are at risk, particularly those with co morbidities of old age such as diabetes, atrophy of subcutaneous fat, debilitating illness, frailty or paralysis.

Keywords: Bed sores, pressure sores
In this part of our country, which has increasing life expectancy, the problem of pressure sores is a strain on the caretaker, with additional strain on the family economy and human resources. Additionally, caretakers are usually required to cater to the nursing of the affected elderly person. Rough estimate of about 6% of those above 70 years of age are believed to suffer from pressure sores.

Etiology

In the normal seated position or lying posture, the bony prominence of sacrum or ischium transmit the body weight on to the bed or chair across a pad of subcutaneous fat and skin. This area of skin and subcutaneous fat pad is under stress by the constant pressure of the body weight, which minimizes the blood flow during that posture, after a while leading to the “pins and needles” sensations of the back or buttocks, which forces the normal person to shift his weight. This protective movement is absent in the terminally ill, the frail elderly, and this sensation is absent in those with neuropathy or paraplegia. The skin and subcutaneous tissue overlying these bony prominences undergo ischemic necrosis, and secondary infection sets in, abscess formation and complications follow. A few other common areas of pressure ulcers are - heel, ankle, around the lateral knee, trochanter of femur, elbow and occiput.

Contributing factors

The atrophy of subcutaneous fat overlying bony prominences makes it more vulnerable to ischemia. In the elderly, this is a contributing factor. Comorbid factors in the etiology and prognosis (like diabetes, hypertension, hypothyroidism, immune deficiency states) are common. Wetness of the region, particularly for those who are using diapers and those with loose stools, are at high risk since the skin gets macerated and easily infected.

Signs and symptoms

Staging of pressure sores makes it easier to plan the treatment.

• Stage I is redness of skin over the bony prominence, indicating early ischemia of skin.
• Stage II is dark or blistering skin signaling death of partial thickness of skin
• Stage III is necrosis of full thickness of skin and exposed subcutaneous tissue
• Stage IV is necrosis of entire pad of subcutaneous fat and skin, with exposure bone, muscle or tendon

The local complications are likely, with abscess formation, spreading infection and necrosis and sepsis, exposed bone or joints.

Prevention and Treatment

Stages I and II can be treated if recognized early, and worsening can be prevented by changing position frequently and by keeping the area dry and clean with local application of antibiotic cream and peripheral application of zinc oxide paste in petrolatum gel. The mainstay of management is the avoidance of pressure in the region by frequent change of position and maintenance of the area clean and dry.

It is most important to advise foam pads for those who are sitting and airbeds for those who are bedridden. Newer forms of pressure distribution are available in the market, with cushions that give alternating differential distribution of pressure, just as much as sequential pressure changes are possible for airbeds. When lying supine, it is important to place foam pads under lower calves to lift ankles slightly off the bed. When lying in bed, change position at least every 2 hours. This will go a long way in prevention of pressure ulcers.

Stages III and IV require surgical intervention after debridement. However, this is a long drawn out procedure, success of which depends on the nursing care. Treatment at this stage would entail debridement, topical and systemic antibiotics and local debriding agents, vacuum assisted closure treatment etc. Often the general condition and morbidity precludes the possibility of surgery in the elderly. However, surgical closure is possible and effective in the younger patients and often necessary in paraplegic bedsore patients.

Pre and 2 months post-operative pictures of a 3rd degree pressure ulcer

Conclusion

The prevention of pressure sore is far easier than cure, which would be long and expensive, and sometimes elusive. The information is more important for the caretaker than for the patient. Awareness of the possibility of pressure ulcers developing in any person who is bed ridden, debilitated, paralyzed, cachexic or elderly should be in the minds of the family members, caretakers and medical personnel.

References

1. Chung, K., Gosain, A., Gurtner, G., Mehrara, B., Rubin, P., Spear, S. and Thorne, C. (2013). Grabb and Smith's Plastic Surgery. 7th ed. Wolters Kluwer, pp.989-997.

2. Bauer, J. and Phillips, L. (2008). MOC-PSSM CME Article: Pressure Sores. Plastic and Reconstructive Surgery, 121(MOC-PS CME Coll), pp.1-10.

3. Krause, J., Vines, C., Farley, T., Sniezek, J. and Coker, J. (2001). An exploratory study of pressure ulcers after spinal cord injury: Relationship to protective behaviors and risk factors. Archives of Physical Medicine and Rehabilitation, 82(1), pp.107-113.

4. Tchanque-Fossuo, C. and Kuzon, W. (2011). An Evidence-Based Approach to Pressure Sores. Plastic and Reconstructive Surgery, 127(2), pp.932-939.

Pressure Sores In The Elderly: Prevention And Treatment