Journal Review: The Development of Pressure ulcers among older adults and co-morbidities overview.

Pressure ulcers also known as bedsores, decubitus ulcers and pressure sores are localized injury to the skin and/or underlying tissue, that usually occur over a bony prominence like the sacrum, coccyx, heels, or hips, which can be due to immobilization, lying in bed for extended periods of time and frailty.

Reduced immune protection, inflammatory factors, hormonal changes, impaired blood perfusion and degenerative changes are some of the many factors acting together synergistically to cause pressure ulcers in the functionally impaired frail older population.

Pressure ulcers professional advisory committees: NPUAP and EPUAP classified the causes of pressure ulcers into Direct and Indirect. The Direct causal factors included; immobility, skin/pressure ulcer status and poor perfusion.

Indirect factors consisted of; moisture, sensory perception, diabetes, low albumin and poor nutrition, old age, medications, pitting edema, infections, acute illness, raised body temperature and chronic wounds .

This article goes on to explain that chronic diseases with prolonged durations are debilitating to patients and  can contribute to reduced mobility, reduced muscle strength,  physical inactivity and weight loss, leading to increased susceptibility for pressure ulcers.

Studies such as Coleman et al. 2014 mentioned some of the chronic diseases/co-morbidities that can predispose older adults to pressure ulcers including diabetes, congestive heart failure, cardiovascular disease, stroke, peripheral vascular disease, chronic kidney disease, chronic pulmonary disease/COPD, dementia/neurodegenerative disease, osteoarthritis, osteoporosis and obesity.

The studies went on to show that among the chronic diseases, diabetes, stroke, and advanced dementia seemed to be most strongly associated with pressure ulcers, peripheral vascular disease and diabetes were also particularly strong causal factors for heel ulcers.

Many people with advanced chronic conditions will develop complications which contribute to the development of pressure ulcers, some of this complications include: malnutrition, anemia of chronic disease, recurrent infectious diseases, hospitalization and poly-pharmacy.

Pressure ulcers may be unavoidable in patients with these chronic conditions, given circumstances such as reduced mobility among patients with low BMI, low albumin and hemoglobin, high inflammatory markers (CRP and ESR) associated with these conditions and with hemodynamic instability (low cardiac output, hypotension) and chronic complications.

Pressure ulcers are a heavy burden on the health care team, especially on  the nursing staff, and require increased care by the medical personnel in all settings. Pressure ulcers are cited as one of the seven major causes associated with short term mortality in Nursing Home residents.

Identifying the key risk factors and impact of co-morbidities on pressure ulcer development and managing the chronic diseases and their complications is the core of prevention and treatment for avoidable or unavoidable pressure ulcers.

The patient, family, and health care team should be adequately informed about ways to improve preventive measures such as managing anemia, optimizing oxygen and blood supply, maintaining mobility and muscle strength, proper wound management, minimizing bedrest, stroke prevention, judicious use of antibiotics and careful attention to medication side-effects, as well as optimizing nutrition and careful weight monitoring.

Implementing these preventive measures, alongside more traditional interventions such as pressure relief devices and repositioning will optimize treatment for pressure ulcers.

In conclusion, changing the treatment priorities to control the manifesting symptoms of both avoidable and unavoidable pressure ulcers ultimately enhances the quality of life and decreases mortality for an elderly patient.

Written by : Dr. Iboro Udoete, M.D

References:
Efraim.J, Jeremy. B, Joshua. P, Jacob. M (2018) An overview of co-morbidities and the development of pressure ulcers among older adults. Biomed Central, BMC Geriatrics 2018; 18: 305.

https://en.wikipedia.org/wiki/Pressure_ulcer.

Photo by Martha Dominguez de Gouveia on Unsplash

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