Bedsores, also known as pressure ulcers, are a serious concern for family caregivers and medical professionals in long-term care settings and hospitals. People who are bedridden or spend significant time in bed or a chair and cannot shift positions on their own are at risk. While a small, irritated area of skin does not sound like a huge concern to the average person, this minor annoyance can quickly develop into a major health problem for frail elders.
Firstly, Louise Aronson, MD, geriatrician, Professor of Medicine at the University of California, San Francisco, and author of A History of the Present Illness, wants to clarify some terminology that may confuse caregivers. The terms bedsore, pressure sore, pressure ulcer, and decubitus ulcer all refer to the same problem. “Pressure ulcer is the preferred term these days,” Dr. Aronson says, “because pressure is the main culprit and these wounds can certainly happen in places other than beds.”
How Do Pressure Ulcers Form?
Pressure ulcers are areas where the skin and/or underlying tissues have been damaged, often leading to an irritated, open wound. “This happens when tissue is compressed between two relatively hard surfaces, such as a bed or chair and a bone inside the body,” Dr. Aronson explains. “The result is essentially the skin equivalent of a heart attack or stroke: the blood supply is cut off to that area and the deprived tissue becomes injured and dies.”
There are three main causes of pressure ulcers:
- Pressure from sitting or lying too long without shifting position;
- Friction or rubbing, which can occur during transfers, such as when the one’s body is dragged over bedsheets; and
- Shearing, which occurs when one’s body slides in a chair or bed so that the skin slides or pulls away from the supportive tissues below it.
Of these, Dr. Aronson says that pressure is by far the most common culprit. “Of course, it is not quite that simple, or we would all have these wounds as a result of our everyday activities, but some people are at higher risk than others,” she notes. “The skin of older adults offers much less protection from injury than younger skin.”
People who are paralyzed or have severe mobility issues may be unable to move themselves even subtly to allow increased blood flow to compressed areas. Those who are bedridden or wheelchair bound are at particularly high risk.
Moisture from a fever or incontinence issues also makes the skin weaker and more prone to irritation. Chronic health conditions and certain lifestyle factors can increase this risk as well, including cancer, stroke, multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, diabetes, malnutrition, smoking, chronic obstructive pulmonary disease (COPD), peripheral artery disease (PAD), heart failure and hip fractures.
The Signs of Skin Breakdown
Dr. Aronson stresses that it is always better to prevent a serious medical problem than to deal with it after it has already caused significant damage. If areas of irritation are detected early on, proper intervention and skin care can prevent the development of painful, open wounds. This is incredibly important since these sores can become very deep and even infected.
The first signs of pressure sores appear when the skin is still intact. Both family and professional caregivers should regularly inspect care recipients for the following signs of skin breakdown.
- Changes in skin color. Keep an eye out for blue or purple marks in individuals with darker skin and pink or red marks in those with lighter skin.
- Unusual fluctuations in temperature. Excess warmth indicates inflammation, while coolness indicates little or no blood flow to the area, both of which are bad signs.
- Changes in tissue consistency. Affected areas may feel exceptionally soft or boggy and different from similar tissue nearby.
- Unusual sensations. Numbness or tingling often occurs in at-risk areas.
Other worrisome signs include blisters or abrasions, signifying an existing superficial injury that can easily worsen. “Deep bruises over at-risk areas, which are actually more serious, often indicate significant damage below the skin,” warns Dr. Aronson. “This is common after a frail senior falls. It may look like a simple, nasty bruise, but it should be carefully monitored in case it turns into a sore.”
Common Locations of Bed Sores
Different body positions are associated with certain vulnerable spots where bedsores usually develop. For example, sitting is most likely to cause sores on a patient’s bottom and back. Another high-risk position is lying down, which can cause sores in any of the following places:
- Sacrum (the large bone at the base of the spine just above the tailbone)
- Heels of the feet
- Sides of the hips (more specifically, parts of the femur called trochanters and the iliac crests of the pelvis)
- Pelvic “sit bones” where weight is placed when sitting (called the ischial tuberosity)
- The back along places where the vertebrae protrude
- Any areas of the head that are in contact with the bed surface, a pillow, etc.
“Other places include the ears, the insides of the knees, ankles, shoulder bones, elbows, and anywhere else that may be pressed against a hard surface for extended periods of time,” emphasizes Dr. Aronson. “This may be caused by something as simple as a leg against a bedrail or a chin resting against a collarbone.”
How to Prevent Pressure Ulcers
There are special products, positions and accessories that can help prevent skin breakdown, but the most important factor is closely monitoring a loved one’s skin condition on a regular basis to know when these tools are needed.
Dr. Aronson recommends the following preventive measures.
- Frequent changes in positioning at least every two hours. This includes alternating from standing to sitting and moving from one side of the body to the back and then to the other side when lying down.
- Protecting at-risk areas with extra cushioning. For example, putting pillows between the legs in bed, using special mattress overlays or chair/wheelchair cushions that are proven to decrease pressure over time can be very useful. These can be made of foam or gel or contain water or air. Regular cushions and foams help but only very briefly, and some can actually increase harm, so do your research before making a purchase.
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- Regular (at least daily) skin checks of at-risk areas.
- Keeping skin lubricated (lotions and creams make the skin more resilient) and free of excess moisture, which increases the risk of skin breakdown. Barrier creams should be used regularly after every adult brief change to promote skin integrity. Even though moisture is detrimental, overly dry, cracked areas of skin can pose problems as well. Use mild soaps and warm water when bathing or cleaning soiled areas to prevent infection.
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- Provide nutritious meals that include protein, vitamins and minerals. There is no one best diet, but inadequate nutrition can slow or stop healing and regenerative processes. Caloric intake is also important for preventing significant weight loss. Thin people tend to have less body fat, muscle mass and other tissue to help cushion commonly affected bony areas.
How Pressure Ulcers are Treated
If a loved one develops one of these wounds, it is important to understand the severity of the injury to devise an appropriate course of treatment. They are classified into four general stages, and there are two additional factors that dictate the best possible treatment options.
Classification of Pressure Ulcers
- Stage 1: Intact skin presents with changes in color, temperature, consistency or sensation. Administer immediate pressure relief and gentle cleansing and conditioning of the skin with mild soap and moisturizing lotion.
- Stage 2: Characterized by a shallow ulcer with only pink tissue in it or a blister filled with clear fluid or blood. Special gels and creams are applied to the shallow ulcer once or twice daily and then covered with gauze. Blisters are closely observed and sometimes covered with a thin, transparent film for added protection.
- Stage 3: Consists of a deeper ulcer, which may extend down to subcutaneous fat and may have yellow ‘slough’ tissue or a thin scab. Deeper ulcers often require multiple treatments. The ulcer base must be kept moist, and this can be done with the same creams used for Stage 2 wounds if the ulcer bed is clean. These sometimes require other treatments, including cutting away the dead tissue or applying creams that help it dissolve. If there is a defect because the wound is deep, the ulcer must be packed. Many forms of insurance pay for pressure relief mattresses and other devices for Stage 3 and 4 wounds.
- Stage 4: A deep ulcer that extends down to bone, tendon or muscle. Also, wounds at this stage often extend under the surrounding intact skin or tunnel into deeper tissues. Eschar (dead tissue), slough, scab or some combination of these may also be present. These wounds often require cleaning out of dead tissue with a scalpel or scissors, called debridement. This can be done by a professional in the home or at a clinic, but more extensive damage that is very deep near the intestines or other critical organs may require surgical attention. After debridement, the treatment is like that of a Stage 3 wound. Injuries of this stage always require careful, regular monitoring and treatment by experts.
- Unstageable: This category describes wounds in which eschar (usually yellow, tan, gray or brown in color) or a scab (black or brown) covers the base, so it is unclear if it is Stage 3 or 4. Ideally, these are treated by removing dead tissues, staging the wound and then treating it accordingly.
- Deep Tissue Injury: These often develop in high-risk areas and present as purple or maroon skin discolorations with changes in temperature, consistency and/or sensation. These signs indicate serious injury below the intact skin. These unique wounds can quickly develop into high stage ulcers, even with optimal treatment, and require monitoring at least daily in case the deep wound opens to the surface or becomes infected. Pressure relief is essential.
“There are many treatments for each stage, so this list merely highlights common options,” advises Dr. Aronson. “For all but the most superficial wounds that respond to efforts to decrease pressure or friction, it is very important to seek care from a doctor, nurse practitioner, physician assistant (PA) or wound care nurse with specialized expertise in these injuries.”
Regardless of the stage of the wound, decreasing pressure to the affected area is necessary to prevent worsening and begin healing. If pain persists once pressure has been taken off the affected area, Dr. Aronson urges family caregivers to seek medical care immediately for their loved ones. This may be a sign of a serious infection or other complication.
Complications of Pressure Ulcers
The most common complication is a worsening wound or development of more wounds as a result of not receiving proper medical care. Dr. Aronson warns that wounds can become infected and even lead to life-threatening systemic infections, like sepsis or infections in the underlying bones (osteomyelitis) that must be treated with weeks to months of intravenous antibiotics.
“More severe wounds can permanently damage muscles and nerves or leave defects in the body,” says Dr. Aronson. “Sites of past wounds are also at higher risk for new pressure ulcers to develop.”
For people who are very old or terminally ill from cancer, heart disease, advanced dementia or other serious conditions, pressure ulcers can be a sign of the body shutting down as death approaches. “For family members, the appearance of a bedsore is a very important reason for discussing a loved one’s priorities for end-of-life care and enlisting help from a specialist in geriatrics or palliative care,” Dr. Aronson advises. “This is often an appropriate time to consider hospice care since their nurses and other staff can help manage the wounds in the context of the patient’s priorities and comfort.”
The take-home message is that pressure ulcers are preventable and treatable. However, they can appear and worsen very quickly, so repositioning and consistent skin care and inspections are crucial. It may be uncomfortable for you and your loved one to look for signs of skin breakdown, but it is a necessary component of senior care.