Have You Tried Prevention Tips for Pressure Sores in Dementia?

One way to prevent pressure sores is to make sure shoes fit well
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What Are Pressure Sores?

Often called bed sores, decubitus ulcers or pressure ulcers, pressure sores are areas of damaged skin that result from too much pressure or weight on the area. The damage can be on the surface or go deep down, even into the muscle and bone.

Areas of the body at particular risk for skin breakdown include the buttocks, coccyx, heels, ankles, shoulder blades, back and sides of the head, ears, elbows and hips.

There are different stages of pressure ulcers ranging from stage 1, which is a reddened area, up to stage 4 where muscle, tendon or bone is visible. Pressure areas can also be classified as unstageable, where you can't tell how deep the injury to the tissue is, or as a deep tissue injury where there's a bruise-like purple area or blood blister covering tissue that feels "mushy" or warmer compared to the skin around it. 

Why Do Pressure Sores Develop?

Pressure sores often develop as a result of limited mobility, poor nutrition and illnesses. In late stage dementia, physical functioning is affected and the ability to move around declines. Thus, the person may remain in the same position for too long- whether that's in bed or sitting in a chair- placing too much pressure on certain parts of the body and increasing the risk for pressure sores.

Risks of Pressure Sores

Several health conditions place people at a higher risk of pressure sores.

Nursing homes and other care facilities use tools like the Braden Risk Assessment Scale to help identify the residents at higher risk for skin concerns. These types of scales provide you with a number that quantifies the level of risk for each person, and that risk level should trigger multiple preventative interventions.

However, you can also review the risks below that have been identified by researchers as being tied to a higher risk of skin injury.

What’s So Bad about Pressure Sores?

Pressure sores can cause significant pain, and the tissue can eventually die and require removal, such as amputation. Sepsis, a systemic life-threatening infection, can also develop in pressure sores. Pressure sores have been correlated with an increased risk of depression and also with death.

Because of the potential for pressure sores to affect quality of life and over-all health, pressure sores were identified, among other factors, as an important measure of quality among nursing homes. The percent of residents with pressure sores- and specifically those that developed while in the facility as opposed to those that were present before the person came to the facility- is one way to assess the quality of the care a facility provides.

Prevention in Dementia

Caregivers for people with dementia- including family members, friends and paid caregivers such as home health care nurses or nursing home staff- need to be vigilant in order to prevent pressure sores. Preventative measures can include:

  • Regular skin assessments

Visually inspect skin, especially over high risk pressures points such as heels, coccyx, and buttocks on a regular schedule. A good time to do this is when assisting the person with bathing. Scheduling both bathing and the skin assessment on the calendar is helpful in making sure this doesn't get forgotten.

  • Floating heels on a pillow

Place a pillow under the calves- not the knees- so that the person's heels are "floating" in air instead of resting directly on the bed mattress.

  • Foot cradle

This is a tent-like device that prevents the sheets and blankets from resting directly on the feet of the person who is lying in bed.

  • Foam at the end of the bed

Place protective foam for the feet to rest on, instead of simply allowing them to rest on the mattress.

  • Regular position-turning and shifting

Assist with regular turning or shifting of positions so that different areas of the body take turns bearing its weight.

  • Adequate incontinence products and care

Many people with dementia develop incontinence. Use high quality incontinence pads and pull-ups that wick the moisture away from the skin, and change them consistently. Gently wash the skin with a clean washcloth instead of rubbing it.

  • Moisture barrier lotions

Some creams, such as Baza can also protect the skin from incontinence.

Medicare will sometimes pay- either at home or in a facility- for physical and occupational therapy to evaluate and determine the most appropriate positions and seating interventions for comfort and skin protection.

  • Assess for contractures

Contractures- where skin on skin contact is constant- can increase the risk of pressure sores. For example, if a person's arm tightens up and involuntarily bends at the elbow because of a stroke, that skin on the inside of the elbow is at a higher risk because moisture and heat can get trapped there.

  • Use pillows for positioning in bed

Consider placing a pillow between the person's knees when they're on their side in bed to prevent pressure from knee to knee contact. Or, you can place a pillow behind the back to vary the position slightly.

  • Ensure good positioning in a wheelchair or chair

Be aware of positioning. For example, if your loved one always leans to the left in her wheelchair, using foam cushions to protect that left side can help prevent pressure points. There are also special cushions to place in the seat of the wheelchair that help with pressure sore prevention.

  • Add padding or cushions to areas that increase risk

For example, if the person's foot is always resting directly on the metal foot pedal in the wheelchair, pad the foot pedal to protect their foot.

  • Use special bed mattresses

You can order special pressure relieving mattresses, including alternating air pressure ones that move air around inside them to relieve the pressure for someone who is at high risk. Under certain circumstances and with a physician's order, Medicare may pay for bed mattresses.

  • Nutrition and supplements

Providing additional protein in the diet can assist in prevention and healing of skin.

  • Limited time up 

If, for example, your loved one has a high risk or a skin problem on his buttocks, you may need to help by limiting how long she can sit up in a chair at a time.

Encouraging good fluid intake can contribute to healthy skin.

  • Lift- don't slide

Be sure that when you are helping someone change positions, you are actually lifting her instead of sliding her across the sheets in her bed. Sliding skin on a surface such as sheets can cause sheering, where the fragile skin is damaged by the friction of the contact with the sheet. A draw sheet, which is a smaller sheet positioned under someone in bed, can help you and another person lift the person from each side to turn them.

If the person is able, movement and blood flow from physical exercise can be helpful in preventing pressure sores.

  • Mechanical lifts

Sometimes, a machine to help lift and re-position someone is necessary to safely care for him.

  • Pat- don't rub

When bathing, be sure to pat the person's body dry with a towel, rather than rubbing it dry.

  • Be careful with bed sheets

A bed sheet tucked tightly around someone can restrict mobility and increase the likelihood of pressure sores. Lay a sheet loosely over the person instead.

  • Foam boots

Some people benefit from a foam boot on the foot that protects the heel, ankle and toes.

  • Ask for help

Finally, if your loved one is at risk of pressure areas, don't hesitate to advocate for him by contacting the physician for help getting the resources and equipment in place that will be the most helpful.

Sources:

Alzheimer’s Society. Pressure Ulcers (Bed Sores). May 2013. https://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=132

International Wound Journal. 2015 Nov 20. doi: 10.1111/iwj.12535. Exploration of pressure ulcer and related skin problems across the spectrum of health care settings in Ontario using administrative data. http://www.ncbi.nlm.nih.gov/pubmed/26584833

Hopkins Medicine. Chapter 30- Pressure Sores. http://www.hopkinsmedicine.org/geriatric_medicine_gerontology/_downloads/readings/section8.pdf

US Department of Health and Human Services. Agency for Healthcare Research and Quality. Long-stay nursing home care: percent of high-risk residents with pressure ulcers. April 15, 2013. https://www.qualitymeasures.ahrq.gov/summaries/summary/38336?

US National Library of Medicine. Preventing Pressure Sores. July 30, 2014. ​https://medlineplus.gov/ency/patientinstructions/000147.htm

US National Library of Medicine. Stages of Pressure Ulcers. Accessed February 6, 2016. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0057179/

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