Pressure Sores

By Chris Woolston

In the end, Superman was brought down by bedsores.

Christopher Reeve, the actor who played the superhero in four movies, died in 2004 of complications from infected bedsores that led to blood poisoning and heart failure, 10 years after a horse-riding accident left him paralyzed from the neck down. (He also had an allergic shock reaction to the drug used to treat the systemic infection from the sores, which may have sent him into cardiac arrest.) Reeve's death underscored the danger of bedsores -- more properly called pressure sores -- one of the most common and most dangerous complications facing people with limited mobility.

Nursing homes and health care workers have long recognized the importance of preventing pressure sores, and now family caregivers everywhere are taking up the cause. If you're caring for a relative who spends much of the day in bed or in a wheelchair, you too will have to join the fight.

The word "sore" hardly captures the seriousness of the problem. "It's a huge quality-of-life issue," says Catherine D'Amico, PhD, an assistant professor at the Hunter Bellevue School of Nursing in New York City. Pressure sores can turn an already unpleasant situation into pure agony, she says, and can permanently damage skin and bone. As the case of Christopher Reeve illustrates, they can also be fatal. According to a report from Harvard Medical School, several thousand Americans die each year from complications associated with pressure sores.

It may take diligent care to prevent pressure sores, D'Amico says, because a seriously ill person can develop bedsores very quickly. In other cases, avoiding the sores is a relatively simple task. But in all situations, a well-informed, dedicated caregiver will be the best defense.

What are pressure sores?

The human body isn't meant to stay still. Even during sleep, healthy people will toss and turn throughout the night, and for good reason. If a person stays in the same position for several hours, the weight of the body will begin to cut off blood supply to areas of skin. A sore develops when the blood supply to a specific spot remains too meager for too long.

People who spend most of their time in bed are especially vulnerable to sores on their tailbone area (sacrum), hipbones, or lower back. The sores can also form on other places that don't have much fat for cushioning, including heels, the back and sides of the head, the shoulders and shoulder blades, and the backs and sides of knees, ankles, and toes. People in wheelchairs also tend to develop pressure sores where their buttocks meet the chair.

In early stages, sores look like small patches of discolored skin. They may be itchy and warm to the touch. In fair-skinned people, the mark will most likely look red. In people with darker skin, newly formed sores can look blue, dark purple, or ashen.

If not treated right away, the sore will grow larger and deeper. As it moves through the top layer of skin, a pressure sore may look like a blister that has been rubbed raw. If nothing is done, the sore will burrow even farther, creating an unsightly open wound that can easily become infected. In the worst cases, open sores can be as wide as saucers and can reach all the way to the bone. The tissue might also become black before it breaks down.

Infected sores may start to ooze thick yellow or green pus. The sore may smell foul and the skin around it become red, swollen, and tender. When a deep sore becomes infected, the infection can travel to the bloodstream, a potentially fatal complication known as sepsis. Serious infections are especially common in people with ailments that affect control of the bowels, because bacteria from fecal matter can easily infect a wound.

Who is at risk for pressure sores?

Anyone who spends their days in bed or in a wheelchair can develop pressure sores. Some people have conditions that make bedsores especially likely.

People who are partially or completely paralyzed are at highest risk. Diabetes and other conditions that slow blood circulation can also make a person vulnerable to sores. The sores are especially common in people over 70, largely because skin thins with age.

People who are underweight don't have much natural cushioning to protect themselves.

People who lack awareness of their surroundings -- perhaps because of Alzheimer's or other forms of dementia -- may not shift positions as much as they should. Malnutrition can make the skin especially fragile and prone to sores. This is especially common in people with end-stage diseases who are malnourished, whose pain makes them resist position change, or who prefer to rest in a certain position.

How can pressure sores be prevented?

Although minor sores can heal quickly, it's far better to prevent them in the first place, D'Amico says. If your relative spends large amounts of time in bed, consider investing in a mattress or mattress pad specifically designed to reduce pressure.

For people at relatively low risk of pressure sores, a foam pad or a sheepskin on top of a regular mattress may offer plenty of protection. For a little extra money, you can invest in a pad made of memory foam (the type that molds to the body). Other pads filled with gel, silicone, water, or beads promise to relieve pressure, but there's not much hard evidence that they really work. Pads equipped with air pumps that automatically shift the pressure against the body are another good option.

People who are especially vulnerable to pressure sores might do better if the entire mattress automatically inflates and deflates to distribute pressure. Such air mattresses can cost from several hundred dollars to over $1,000, and they aren't always covered by insurance (Medicare and hospice programs will generally cover the cost, however). Your relative's doctor or nurse should be able to help you choose a pad or mattress that's right for your situation. You might also want to check with a hospice official or home nursing agency people who work with these organizations are often very knowledgeable about such issues.

People in wheelchairs also need to be properly cushioned. Cushions filled with foam, gel, air, or water can all help prevent sores. Ring-shaped cushions aren't recommended because they don't evenly spread pressure. A pressure-release chair that tilts to shift a person's weight can greatly reduce the risk of sores.

Even when the right cushioning is in place, you may have to help your relative shift positions often to avoid sores. If he can't move on his own, you'll have to help him move at least once every two hours, even during the night. Ask your relative's doctor or nurse to show you the best way to shift his body. They can also show you how to prop cushions around the back and legs to keep him from rolling back into the same position. If it's painful to move, the doctor might prescribe painkillers in order to help them change positions.

People in wheelchairs need to move regularly, too, especially if they don't have a pressure-release chair. Encourage your relative to regularly shift his weight if possible. If he can't move on his own, you can try shifting him every 15 to 30 minutes. If your relative does have a pressure-release chair, you may not have to shift him around nearly so often. Still, it's a good idea to regularly check for signs of pressure sores.

Whether or not a person can move on his own, proper positioning is important. Try to keep your relative from resting directly on his hip bones. If he's lying on his back, he should have a pillow or cushion to support his lower legs. His knees and ankles shouldn't be touching each other, and the head of the bed shouldn't be elevated more than 30 degrees.

If your relative isn't eating well, improving his diet may also give him extra protection against sores. Protein is especially important. If your relative doesn't feel like eating meat or cheese, try alternatives such as eggs or peanut butter. If he has lost his appetite, try feeding him several small meals instead of a few large ones.

You or the primary caregiver should also inspect your loved one's body for the beginnings of pressure sores at least twice a day, perhaps during a sponge bath.

How are pressure sores treated?

If you notice a pressure sore early, you can give it a chance to heal by making sure the spot gets sufficient cushioning. If you haven't already tried putting an extra pad on the mattress, now's the time to get one. If you already have a mattress pad, you may need to put another small cushion or foam wedge under the sore until it has a chance to heal. In the meantime, keep the area clean with water and mild soap.

If the skin is broken or there's an open sore, contact your doctor right away -- this is no longer a job that you can tackle on your own. And if you see signs of infection -- including pus, swelling, or a foul odor -- get your relative emergency treatment.

The doctor will clean out the wound and, if necessary, cut away dead tissue. You'll learn how to clean and dress the wound at home. In severe cases, surgery may be necessary to close the wound and prevent further damage. Don't expect a minor procedure: Treatment for a single severe bedsore can be difficult and very expensive.

With so much at stake, it's no wonder that pressure sores have become a top concern in nursing homes and other long-term care facilities. In fact, Medicaid and Medicare now grade nursing homes largely on their rates of pressure sores. "The rates of sores are a clear sign of the quality of care," D'Amico says. However, in home care settings, bedsores will appear from time to time; families shouldn't berate themselves if for some reason this happens. The key is to be as diligent as possible to prevent sores from developing in the first place, but if one appears, prompt detection and treatment are the next best thing.

It's true at a nursing home. And it's true at your own home, too.

References

Interview with Catherine D'Amico, RN, PhD

Mayo Clinic. Bedsores (pressure sores). 2009. http://www.mayoclinic.com/health/bedsores

American Academy of Family Physicians. Pressure sores. http://familydoctor.org/online/famdocen/home/seniors/endoflife/039.html

British Medical Journal. Best Practices. http://www.besttreatments.co.uk/btuk/conditions/1000525664.html

John A. Hartford Foundation. Institute for Geriatric Nursing. Pressure ulcers in older adults.

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