Act quickly to prevent bed sores

They’re the bane of sedentary elderly or immobile people.

Commonly called bedsores or pressure sores, these injuries result from sitting or lying down without changing position for prolonged periods. This can cause a breakdown of skin and injury to underlying tissue that can become an open wound. They are tough to get rid of and a potential source of localized or systemic infection.

Pressure injuries often occur among elderly who are sedentary and/or have dementia, patients in nursing facilities and hospitals and disabled people, such as those with spinal cord injuries, said Patrick J. Flynn, MD, a general surgeon board certified in wound care, who is medical director of Cape Cod Healthcare’s Wound Care Centers in Hyannis and Bourne.

These injuries typically occur from body weight exerting pressure over a bony area, such as the coccyx or tailbone, hip, elbow or heel, he said. Other locations include the sacrum (area above the tailbone), scapula or shoulder blade, shoulder, occiput (bottom back of the skull) and ear, according to a January 3, 2024, National Library of Medicine StatPearls article. An estimated three million Americans get pressure ulcers each year, according to the NIH.

“Pressure basically pushes all the blood flow out of the tissue creating ischemia (poor perfusion),” Dr. Flynn said. “Poor perfusion in conjunction with tissue deformation can lead to tissue death and tissue breakdown.”

From Inside Out

Deep tissue injury can be occurring even if the skin above looks unbroken. The only manifestation of a deeper process may be some skin discoloration (non-blanchable redness, purplish discoloration).

“Almost everyone thinks they occur purely from the outside in,” Dr. Flynn said, and are surprised when suddenly a deep wound appears. “The deeper tissues can die first with skin breakdown occurring secondarily.”

Deeper ulcers can result in bone infection, even amputation, according to The Joint Commission, a global body dedicated to improving healthcare.

“We are able to heal most of these, but unfortunately, not all of them,” Dr. Flynn said.

Odd as it may seem, some patients are unaware they have an ulcer until it’s reported by a caretaker, according to the NIH. This can be due to both loss of sensation at the wound site and that many elderly patients with pressure ulcers also have problems thinking clearly. The NIH notes that sustained pressure causes discomfort in people with normal cognitive and sensory functions, prompting them to change position, if they are not immobile, so they are unlikely to develop a pressure injury.

Not all pressure injuries result from days or weeks with few changes in position, Dr. Flynn said, and not all manifest immediately after an insult.

“The injury can happen in the space of several hours. An elderly patient falls at home and can’t get up” and is left on the floor for a few hours. “Weeks later they may have a related pressure wound.”

Risk Factors

Dr. Flynn identified these risk factors for pressure wounds:

• Temporary or permanent Immobility from spinal injury, neurologic condition or other disability, lengthy anesthesia or prolonged healthcare facility stay.
• Not frequently changing sitting or reclining positions. “It’s not uncommon in the elderly to spend the day sitting,” he said.
• Incontinence and moist skin. Moisture can hasten skin breakdown. It can also make it difficult to move into a new position. Wetness from urine or sweat should be promptly addressed.
• Shear injuries from friction. These can happen when skin, especially moist skin, is dragged, often when attempting to change positions.
• Diabetes and other diseases affecting circulation and pain sensation.
• Malnutrition and dehydration. Proper nutrition is needed to keep skin and underlying tissue healthy.

The Joint Commission added three more risk factors:

• Obesity
• Dementia
• Having previously had a pressure injury

Prevention and Treatment

“The top three things I tell patients: Get the pressure off, get the pressure off, get the pressure off,” Dr. Flynn said.

That goes for both preventing pressure injuries and helping them heal. It requires frequent weight shifts every couple of hours, he said. If there’s a pressure injury on one buttock, pillows or wedges can be used to rotate the patient onto the other buttock, but be careful not to keep all the weight on that side for too long or it may also break down. Coccyx cushions can relieve pressure for tailbone injuries.

“Specialty cushions and mattresses are not enough once a pressure injury develops. They do lessen pressure, but don’t eliminate it,” Dr. Flynn said. “Once there is a wound, the goal needs to be to eliminate pressure to facilitate healing.”

Caretakers and health workers need to be educated to avoid sliding patients to prevent shear injuries, he added. Patients who can do so should lift their bottom off the bed when changing positions and not try to scoot over. Non-friction sheets can help. But whether accomplished by the patient or with help, position changes must be frequent.

“I can’t tell you how often I hear from family members who have a loved one in a nursing facility who is not getting turned often enough” and they either develop a pressure injury or hinder one from healing, Dr. Flynn said. “It’s very frustrating for all involved.”

Patients should keep skin dry in spots under pressure, eat a balanced diet, perhaps with a protein supplement, and drink adequate amount of water every day, he said.

Ulcers may need surgery to remove dead or infected tissue, Dr. Flynn said. What type of dressing used depends upon the depth of the ulcer and whether it’s infected, according to the NIH. In some cases, surgeons create skin flaps or grafts to cover the open wound. Post-surgical recovery can be lengthy and may require patients to lie flat for weeks before attempting to partially sit up for a few minutes at a time.