Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Review: Pressure sores in the elderly can be predicted, prevented, and treated

ACP J Club. 1991 May-June;114:68. doi:10.7326/ACPJC-1991-114-3-068


Source Citation

Smith DM, Winsemius DK, Besdine RW. Pressure sores in the elderly: Can this outcome be improved? J Gen Intern Med. 1991;6:81-93.


Abstract

Objective

To review the literature on occurrence, prediction, and preventive and therapeutic interventions for pressure sores in elderly patients.

Data sources

MEDLINE was searched for the years 1980 through 1988 for English-language studies using the terms decubitus ulcer and elderly; titles under decubitus ulcer in Index Medicus were scanned for the years 1979 through April 1989.

Study selection

Studies dealing only with surgical interventions or with pressure sores related to neurologic disorders or to peripheral vascular disease were excluded. Studies were required to contain original patient data. Studies of prevalence had to have a denominator population; studies of incidence and predictive instruments required an inception cohort; studies of preventive or therapeutic interventions required identified control groups. 102 articles met the criteria.

Data extraction

2 independent observers extracted and verified patient and methodologic data from the studies.

Main results

Prevalence and incidence of pressure sores in elderly patients varied according to stage of sores, location of sores, and other patient variables as well as by site of the investigation. The incidence of pressure sores in nursing homes was about 6 per 1000 patient-days, and, in high-risk hospitalized groups, the incidence was 11 to 28 per 1000 patient-days. The development of pressure sores was predicted most successfully by an instrument monitoring patient movements (positive predictive value [PPV], 92%) and by thermography (PPV, 66%) (assuming that 20% of the population develop sores). Methods requiring observer rating (Anderson, Braden, Vaperm, and Norton scales) had PPVs between 63% and 0%, with varying patient populations, length of observation periods, and reliability checks. In randomized or quasi-randomized trials, comparison of some preventive interventions with routine care indicated that fewer patients developed sores when using mattresses containing polystyrene beads or water, or alternating air pads. No differences were found between topical applications in limited testing. ACTH was more effective than placebo for patients after elective hip surgery. Therapeutic interventions associated with healing of sores included mucopolysaccharide cream, cadexomer iodine, topical gentamicin, collagenase ointment, polyurethane dressing, hydrocolloid dressing, air-fluidized bed, ascorbic acid, and ultraviolet light.

Conclusions

Research into pressure sores is far from complete. However, several validated options exist for predicting, preventing, and treating pressure sores in elderly patients.

Source of funding: In part, Hartford Foundation Faculty Scholars Program.

Address for article reprint: Dr. D.M. Smith, Department of Medicine, 1001 West Tenth Street, Indianapolis, IN 46202, USA.


Commentary

The pressure sore is a common problem afflicting elderly patients in hospitals or nursing homes. This paper highlights the paucity of well-controlled studies of either preventive or therapeutic maneuvers. Although the clinical efficacy and cost-effectiveness of special equipment for prevention have not been established, upgrading general care for patients at risk for pressure sores and educating staff may help to achieve this goal (1).

Once pressure sores develop, treatment requires relief of pressure and high-quality nursing care. In selected patients, air-fluidized beds may help with pressure relief, but these are expensive and increase the risk for back strain among nursing staff. Most agents advocated for chemical debridement have not been adequately studied. Hydrocolloid occlusive dressings and polyurethane film dressings may promote wound healing in more superficial sores and protect from urinary and fecal soilage.

The costs of treating pressure sores are enormous. Therefore, prevention remains the key management principle, and pressure unloading is the cornerstone of both prevention and management. As this review concludes, pressure sores are a major indicator of quality of care, and further research and consensus on outcome measures are needed.

James B. Reuler, MD
Veterans Affairs Medical CenterPortland, Oregon, USA


Reference

1. Moody BL, Fanale JE, Thompson M, et al. Impact of staff education on pressure sore development in elderly hospitalized patients. Arch Intern Med. 1988;148:2241-3.


Update

This review was updated in 1995 (2).

2. Smith DM. Pressure ulcers in the nursing home. Ann Intern Med. 1995;123:433-42.