Madam Chong was a bed-bound 85-year-old who had been admitted to hospital with medical problems. When I examined her, I discovered that she had a pressure ulcer that extended from the middle of her back to the base of her spine, and it likely had spread beyond the muscle into the bone.
There are four stages of pressure ulcers. Madam Chong's ulcer was so extensive that it was classified as unstageable. It was the worst pressure ulcer I had seen.
Her primary caregiver was her domestic helper, who thought that applying powder on the ulcer would dry the wound and mask the stench of rotting flesh. She did not realise that applying powder would aggravate the ulcer.
Madam Chong has advanced dementia and could not tell anyone that she was in pain. By the time I saw her, she had developed severe sepsis, a life-threatening complication from an infection at the base of her spine.
Elderly people in poor health such as Madam Chong are at high risk of developing pressure ulcers, which are injuries to skin and tissue resulting from sustained pressure when a person lies in bed or sits in a chair for lengthy periods of time without changing his position.
Also known as bedsores, pressure ulcers develop most frequently in the areas where the bones are close to the surface. The most common sites are the heels or the sacrum at the base of the spine.
Those who are older than 85 years are most susceptible as their skin has less fatty tissue or cushioning.
They also suffer from poor circulation due to reduced blood supply, which affects skin nutrition and body-heat regulation. This increases the chances of pressure ulcer formation.
Prolonged exposure to moisture also raises the risk of pressure ulcers. The skin becomes "water logged" due to moisture from sweat, in the same way that our hands wrinkle after prolonged exposure to water. This makes it more prone to breakdown.
Incontinence has the same effect, so an elderly person who wears diapers should have them changed regularly to keep the skin dry.
It takes just 30 minutes of sustained pressure for a pressure ulcer to start forming.
In the early stages, redness appears and the area will not blanch or whiten when pressed. Damage beneath the skin begins within two hours of sustained pressure.
After about six hours, the affected area will appear blue or greyish and may be hardened or uneven. If pressure continues, ulceration will occur.
Medical or nursing advice should be sought immediately when an ulcer is detected. Left untreated, an ulcer can become infected, leading to cellulitis, where infection spreads to deeper layers of skin. The risk of blood poisoning rises when this happens, or if the infection spreads to the blood and other organs.
WAYS TO RELIEVE PRESSURE
There are a few ways to keep a pressure ulcer from forming. Chair-bound people should change their position every 15 minutes, or be repositioned by a caregiver every hour. Cushioning devices placed beneath the heels and the sacrum can reduce pressure on these areas. They should try to walk, if they are able to.
Those who are bed-bound should be repositioned every two to three hours, and sit up for meals if possible. Use pillows to raise a bed-bound person's arms, legs, buttocks and hips, to alleviate pressure on bony prominences such as the knees and ankles.
Consider investing in a pressure- relief mattress that distributes weight to prevent pressure ulcers.
A cotton lift sheet placed beneath a bed-bound person will not only make moving and repositioning easier, but it will also prevent the skin from rubbing against the bedding, which can lead to skin breakage from friction.
A schedule should be created for repositioning both bed-bound and chair-bound people, and daily inspections carried out to watch for any sign of a pressure ulcer.
Caregivers should be particularly vigilant if they are caring for the elderly, who have impaired sensation due to conditions such as diabetes, or disorders of the spinal cord, as they may not be able to feel the pain when an ulcer forms.
Good nutrition is one of the most important factors in pressure ulcer prevention. As people age, they eat less due to changes in dentition or difficulties in independent eating.
However, the proper intake of calories, protein, fluids, vitamins and minerals is crucial to maintain tissue integrity and prevent the skin from breaking down.
Supplement drinks can help ensure adequate nutrition to keep the skin in good condition and prevent pressure injuries.
A pressure ulcer can adversely affect quality of life, as the associated pain, odour and anxiety over the treatment and healing process can be difficult to deal with.
By keeping a bed-bound or chair-bound person dry, changing positions regularly and ensuring proper nutrition, caregivers can prevent pressure ulcers from forming.
For frail elderly people, this can mean the difference between health and unnecessary suffering and pain.
•Dr Barbara Rosario is a consultant in geriatric medicine at Changi General Hospital.
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