Pressure ulcers are a common problem in bedridden hospital patients, and can develop into a threat to the overall health of a person. They can even progress beyond a surface wound into an area where the muscle and bone are exposed. Infections can and often do strike, leading to more serious complications such as meningitis, cellulitis or endocarditis. Elderly patients are especially prone to pressure ulcers, which are also known as pressure sores or bedsores.

For elderly people with chronic illnesses such as diabetes, pressure ulcers present even more serious health risks, including lessened response to treatment and greater difficulty in healing. These effects can aggravate chronic conditions in patients whose general health and wellbeing are poor.

Research published in the Journal of the American Medical Association found that the prevalence of foot ulcers in diabetic patients was much higher than the general population, at 15–25% over a lifetime. Cases of foot amputation in patients with diabetes are usually linked to foot ulcers initially. The study recommends screening all patients with diabetes for risk of foot ulcers.

Recent advice in studies on treating pressure ulcers emphasises the importance of a healthy diet and good nutritional intake, with adequate hydration, to help prevent the condition from developing. The nutritional requirements of diabetic patients are a major consideration to be taken into account when treating pressure ulcers. Type 1 and type 2 diabetes cause high blood sugar levels which slow blood flow and hamper healing times.

The importance of nutrition

A white paper from the US National Pressure Ulcer Advisory Panel entitled ‘The Role of Nutrition in Pressure Ulcer Prevention and Treatment’ highlighted that “adequate calories, protein, fluids, vitamins, and minerals are required by the body for maintaining tissue integrity and preventing tissue breakdown.” The paper found that “compromised nutritional status such as unintentional weight loss, under-nutrition, protein energy malnutrition (PEM), and dehydration deficits are known risk factors for pressure ulcer development”.

The paper referred to a further study in the US involving more than 1,500 elderly people in care facilities with supporting evidence that showed that eating problems were a continual factor in the incidence of pressure ulcers. The white paper identified elderly people who rely on others to help them eat, as well as those with chewing and swallowing difficulties, as being less likely to have the healthy nutrition needed to heal from pressure ulcers.

Protein is singled out in the white paper as a vital element of a healthy diet that will aid healing of pressure ulcers.

In the UK, the National Institute for Health and Care Excellence (NICE) recommends the use of nutritional supplements in its guidelines on establishing a healthy diet for adult patients with pressure ulcers. The Patients Association has also stressed the importance of dealing with malnutrition and preventing muscle loss in older patients, which in turn may help with overall levels of care.

In a study on this effect, Kelly Grainger, the head of dietetics and therapies at the Leaders in Oncology Care treatment centre, stated, “Getting the right nutrition is especially important as we age as it can help to prevent and slow down muscle loss. We shouldn’t accept muscle loss and frailty as an inevitable part of ageing as it can have serious health consequences, including longer recovery times, higher chances of complications or even death for people who are malnourished.” It is clear that a healthy diet is vital, particularly for ensuring that older patients with chronic conditions are able to fend off the infections to which they are especially susceptible.

Unfortunately, a healthy diet is not the norm. More than three million people in the UK are affected by malnutrition, and around a third of adults who are admitted into hospital are malnourished. Three quarters of people over 65 who are recovering from a recent illness are not given any nutritional support either in hospital or after discharge. One year later, a quarter of those patients will not have recovered from their illness, according to industry analysis released by private healthcare facilities.

The social dimension

Carole Glencorse, medical director for Abbott Laboratories’ nutrition business in Europe, the Middle East and Africa, spoke of fairly basic but underused solutions: “With the appropriate nutritional support, which can include the use of oral nutritional supplements, overall recovery can be significantly improved, regardless of age.”

One of the first steps suggested by the Patients Association to ensure that people get the nutritional support they need is to screen for signs of malnutrition. The signs include weight loss, loss of appetite and lack of energy.

This approach seems like common sense, but, unfortunately, is often overlooked in busy hospital settings. We spoke to Jos Schols, professor of old age medicine at Maastricht University in the Netherlands and an expert on the effect nutrition can have on pressure ulcers and geriatric care, about what more could be done to prevent elderly patients’ quality of life from being hampered by the effects of poor nutrition.

Diabetes can be an aggravating factor, but nutrition is important in all patients, says Schols. “It is very clear that working on an optimum nutritional status is important for both people with diabetes and without diabetes – this is simply crucial for every patient,” he explains.

Schols points to epidermal studies which show that good nutrition leads to healthy skin and tissue. “If a person is malnourished, then, with or without diabetes, the chances of a quick recovery [from pressure ulcers] is lower,” he says.

Older people are more prone to pressure ulcers for a number of reasons, according to Schols. They may be frail and have mental health problems such as dementia. Often they have multiple health issues and more than one disease, he says, which can lead to complications and a compounding of problems.

Old people can also be ‘socially frail’, Schols says, which means they are unable to access the care they need – and with austerity across many countries and lowered health budgets, many may be on a low income and be socially isolated.

Schols also notes that there is a problem with older people not always taking proper care of themselves and having a balanced meal every day.

“If you have a patient with pressure ulcers and compromised status,” he tells Practical Patient Care, “then you need to look at the patient as a whole and not only at the patient’s ulcers alone,” including the patient’s social condition.

Holistic patient care

An approach by health professionals that considers every aspect of patient care is vital, according to Schols. He is optimistic that things may be on the up for elderly patient care due to growing acceptance in the past ten years that treating pressure ulcers effectively must involve a holistic approach.

“There is more interest in treating the patient beyond the wound,” he says. “It is good that we pay attention to the wound, but if it doesn’t heal then [we should] look at other reasons.”

It is important that more than one professional is included in the care offered to a patient with pressure ulcers, Schols argues. “Wound care should be multidisciplinary,” he says. “There is gradually more awareness that these types of wounds need multidisciplinary attention.”

According to Schols, an assortment of new guidelines on pressure ulcer care are now being adopted in Europe, the Pan-American countries, and some parts of Asia, but how in-depth and helpful they will be varies from location to location. The guidelines stress the importance of looking at every aspect of a patient’s health as an intrinsic part of an effective professional care package.

Specialist wound care centres are now being developed in some countries, such as the UK, Germany and the Netherlands, which use the latest techniques to treat pressure ulcers.

“These new innovative wound care centres are cost-effective as well, because they work in a more integrated and less fragmentary way than in many hospitals or care homes,” he says.

Growing awareness

Schols believes that research into diabetes care is desperately needed, especially to firmly establish the link between nutrition and recovery from pressure sores. Many previous studies have been industry-led and are not independent.

A higher profile for the prevention and treatment of wounds is also needed within the healthcare world, Schols argues. “Many doctors and nurses are not interested enough,” he says.

“You have die-hards who work on pressure sores, but [the condition is] often neglected because [it is] not part of the primary task of a healthcare professional,” he adds.

But there has been some improvement: “At least pressure sores are now usually seen as a complication and not caused by bad nursing performance, which is not true.”

Schols likes the idea of ‘woundologists’ who would specialise in the care of wounds such as pressure sores. Creating a wound care specialism would help to raise the status of this area in healthcare, he believes.

Progress is clearly being made in recognition within the healthcare world that pressure sores need to be treated as part of an overall package of patient care.

Many health professionals are now acknowledging that a patient’s overall health has a major impact on the incidence and development of pressure sores.

With wound care centres being opened in some countries, the standard of care can only rise. New treatment products for pressure sores will be more effective if independent research is carried out into improved treatments for this difficult and persistent problem.

The I-CARE checklist for detection of pressure ulcer risk factors

I = I will check:

C = Clothing. Weight loss can be a sign of malnutrition, so it is important to look at patients’ clothing. Are the clothes loose or ill-fitting? This could be a sign that patients are not eating properly.

A = Appetite. Loss of appetite is a key sign. Are patients eating less? Do they make excuses about not being hungry? Also be aware that with weight loss, dentures can become loose and ill-fitting, making it harder to eat.

R = Rings. Jewellery can often become ill-fitting with weight loss. Keep an eye on items such as wedding rings that people may have worn for years suddenly becoming loose.

E = Energy. With lack of food or appetite and general weight loss can also come a lack of energy. Check whether patients seem more lethargic or struggle to keep up in a way that they never used to.

Source: Abbott Nutrition