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• To refresh your knowledge of the physiological changes associated with ageing
• To recognise the causes and risk factors for the development of pressure ulcers in older people with frailty
• To identify interventions you could use in your practice to prevent and manage pressure ulcers
The incidence of pressure ulcers is highest among older people with frailty. The development of pressure ulcers is a common and challenging issue in this population, which can reduce people’s quality of life and increase mortality risk. Multifactorial processes contribute to the development of pressure ulcers in older people with frailty, including age-related skin changes, comorbidities, polypharmacy, reduced mobility, inadequate nutrition and hydration, and continence issues.
This article discusses the development and management of pressure ulcers in older people with frailty. It also outlines some of the measures that can be taken by nurses and other healthcare professionals to reduce the risk of pressure ulcers developing in this population.
Nursing Older People. doi: 10.7748/nop.2022.e1405
Peer reviewThis article has been subject to external double-blind peer review and checked for plagiarism using automated software
Correspondencelynn.cornish@st-margarets-hospice.org.uk
Conflict of interestNone declared
Cornish L (2022) Prevention of pressure ulcers in older people with frailty. Nursing Older People. doi: 10.7748/nop.2022.e1405
Published online: 21 July 2022
The life expectancy of older adults has increased significantly, due in part to improved living conditions and medical treatment. Globally, life expectancy has increased by more than six years in the past two decades, from 66.8 years in 2000 to 73.4 years in 2019 (World Health Organization 2022). However, this increase in life expectancy has resulted in many older people living with multiple comorbidities, frailty and disability (Suzman et al 2015).
Long-term conditions such as cancer, diabetes and cardiovascular, lung, renal, musculoskeletal and neurodegenerative diseases are more prevalent among older adults than younger people (Jaul et al 2018). As these conditions progress, people may experience impaired motor, sensory, immune and hormonal systems, resulting in geriatric syndromes such as frailty (Maresova et al 2019). These conditions can also result in inadequate perfusion of tissues and organs and peripheral ischaemia, which can contribute to the development of pressure ulcers (Kaitani et al 2010).
Older people with comorbidities may experience polypharmacy (the prescribing of multiple concurrent drugs to one individual), which is associated with a range of complications such as reduced functional and cognitive health status, as well as increased risk of falls, adverse drug events, hospital admissions and mortality (Rieckert et al 2018). Many older adults take one or more medicines that are unnecessary and may experience adverse effects due to drug-drug interactions and drug-disease interactions (Maher et al 2014). Sedatives, vasopressors and corticosteroids in particular have been reported to increase risk factors for the development of pressure ulcers (Lindquist et al 2003, Lyder et al 2012, Cox and Roche 2015).
This article discusses some of the causes and risk factors for the development of pressure ulcers in older people with frailty and considers how nurses can support prevention of pressure ulcers in this population.
• A pressure ulcer can be defined as localised damage to the skin and/or underlying tissue, usually over a bony prominence, resulting from pressure or a combination of shear with pressure
• The development of pressure ulcers is a common issue in older people with frailty that can reduce their quality of life and increase mortality risk
• The redistribution of pressure is the most important factor in maintaining skin integrity, and can be achieved by addressing factors that can affect an older person’s mobility or through repositioning
• Nurses can reduce the risk of pressure ulcers by supporting older people with frailty to mobilise and through effective repositioning, while ensuring adequate nutritional and fluid intake and managing any continence issues
Frailty describes a clinical state of increased vulnerability in older people due to inadequate resolution of homeostasis following a stress event, increasing the risk of adverse outcomes such as falls, delirium and disability (Eeles et al 2012). Any event, for example an infection or a change of medicine, can have a disproportionately detrimental effect on the health status of an older person with frailty (Clegg et al 2013). Older people with frailty usually have three or more of five symptoms – unintentional weight loss, muscle loss or weakness (sarcopenia), fatigue, slow walking speed and low levels of physical activity – resulting in reduced independence (Chen et al 2014). These symptoms can have a significant negative effect on an older person’s ability to maintain tissue integrity, which may result in the development of a pressure ulcer (Jaul et al 2018).
The incidence of pressure ulcers is highest in older people with frailty (Dealey et al 2012). The development of pressure ulcers is a common and challenging issue in this population that can reduce people’s quality of life and increase mortality risk (Khor et al 2014). Pressure is the main cause of pressure ulcers, while risk factors include immobility, inadequate nutrition and hydration, continence issues and underlying health conditions (National Institute for Health and Care Excellence (NICE) 2014). Pressure ulcers can be painful and may become infected, which can result in social isolation, depression and increased hospital admissions. This is distressing for patients and has financial implications for healthcare services (Dealey et al 2012).
The symptoms of frailty and the causes and risk factors for the development of pressure ulcers are interlinked, which can make prevention and management challenging for healthcare professionals.
The skin is the most visible organ of the body and undergoes numerous changes with age that have significant physiological consequences. Changes to the skin in older people with frailty include (Tobin 2017):
• Reduced skin strength and elasticity, due to changes in connective tissue.
• Fragile blood vessels in the dermis (the vascular, thick layer of the skin below the epidermis). This can result in purpura (a rash on the skin caused by internal bleeding from small blood vessels) or haematoma formation.
• Reduced oil production in sebaceous glands, causing the skin to become dry.
• Thinning of the hypodermis (subcutaneous layer – the innermost layer of the skin consisting mostly of fat), resulting in less padding or insulation. Thinner, fragile skin increases the risk of tissue damage, such as skin tears and pressure ulcers.
These changes to the skin, combined with other influencing factors – such as comorbidities, reduced mobility and polypharmacy – place patients with frailty at high risk of multiple adverse outcomes, including pressure ulcers (Hubbard et al 2017). In addition, wound healing time is prolonged in older people, possibly due to a decrease in wound tensile strength, slower rate of fibroblast migration and senescence (ageing) of the immune system (de Castro and Ramos-e-Silva 2018).
A pressure ulcer can be defined as localised damage to the skin and/or underlying tissue, usually over a bony prominence, resulting from pressure or a combination of shear with pressure (European Pressure Ulcer Advisory Panel (EPUAP) et al 2019). All patients are at risk of developing a pressure ulcer, but they are more likely to occur in older people with frailty and in those who are seriously ill, have a neurological condition, impaired mobility, impaired nutrition, or suboptimal posture or a deformity (NICE 2014). Therefore, all patients should undergo a pressure ulcer risk assessment on admission to hospital or a care home using a recognised and validated risk assessment tool, such as the Waterlow score (Waterlow 2005), and following any change in status (NICE 2014). These assessments should inform an individualised care plan that will require updating as the patient’s condition changes (EPUAP et al 2019).
While it should not be used as a stand-alone approach to pressure ulcer prevention, the redistribution of pressure is the most important factor in maintaining skin integrity (Nigim and Salim 2017). This can be achieved by addressing factors that can affect an older person’s mobility or through repositioning, as appropriate.
Older people with frailty are at increased risk of reduced mobility and those who are immobile are at highest risk of developing pressure ulcers (Fletcher 2020a). Muscle mass and strength decrease with age and this process is exacerbated in patients with frailty (Wilkinson et al 2018). Exercise is beneficial even for people with severe frailty and can increase mobility, enhance the ability to perform activities of daily living, reduce the risk of falls, improve gait, increase bone density and improve general well-being (Åhlund et al 2020). Even low levels of exercise can increase muscle strength and improve quality of life (Amireault et al 2017). Patients can be shown how to perform, and encouraged to undertake, simple exercises every 15-30 minutes to relieve pressure to vulnerable areas (NHS 2022). Referral to a physiotherapist is recommended for the development of a regular programme of exercise to strengthen and improve muscle flexibility (British Geriatrics Society 2015). Those who may benefit from using mobility aids should be referred to a physiotherapist and/or occupational therapist to ensure that equipment is suitable in terms of its size or shape, and that the person can use it correctly and feels confident to do so (Muldoon 2017).
The environment should be kept free of clutter and trip hazards, such as trailing wires or rugs, and there should be adequate lighting, particularly in the bathroom at night (Rantanen 2013). Clothing and footwear should be comfortable, well-fitted and with an adequate grip to the sole, while heels should be low or flat (Jellema et al 2019). Loss of hearing and/or a deterioration in eyesight can affect people’s balance and concentration (Fisher et al 2014). Therefore, glasses should be correctly fitted, particularly bifocal or varifocal lenses, since vision can be affected if they slip out of position, while hearing aids should be fitted and adjusted correctly, with their batteries checked regularly.
NICE (2014) guidelines recommend that those at risk of developing a pressure ulcer should not remain seated for longer than two hours. However, for people who are unable to mobilise regularly, or at all, using a reclining chair tilted backwards by 15, 25 or 35 degrees can reduce load and increase blood flow to the skin on the buttocks (Aissaoui et al 2001, Zemp et al 2019). NICE (2014) guidelines also recommend that patients with an established pressure ulcer should not sit out of bed (Stephens and Bartley 2018). However, sitting in a chair for short periods to consume a meal can improve nutritional intake and physical and mental well-being (Anderson 2017). Therefore, the risks and benefits should be assessed and discussed with patients and/or carers and an agreed plan of care should be implemented based on the outcome.
Some patients may require additional pressure-relieving equipment, which may include (EPUAP et al 2019):
• High-specification foam mattresses.
• Alternating air mattress, with or without a tilt system.
• Tilt system placed under the mattress.
• Cushions, for example filled with memory foam, air or gel.
• Prophylactic dressings.
Polypharmacy can have a detrimental effect on an older person’s ability to mobilise because it may cause increased drowsiness and reduced concentration, which can affect alertness and balance, thus increasing the risk of falls (Jyrkkä et al 2010). Therefore, healthcare professionals who care for older people with frailty should have an understanding of the adverse effects of polypharmacy and conduct or request a medication review to determine which are essential and which could be reduced or discontinued (Rochon et al 2021).
Whenever possible, older people with frailty should be encouraged to mobilise with as little intervention as possible. However, some people may require assistance with repositioning. The EPUAP et al (2019) guidelines on the prevention and treatment of pressure ulcers advise that all patients at risk of developing a pressure ulcer should be repositioned in accordance with their individual needs, using two-hourly, four-hourly and six-hourly intervals as a guide. The frequency of repositioning depends on the condition of the patient’s skin, their tolerance of repositioning and their comfort and wishes. Any movement needs to be sufficient to achieve reperfusion of the tissues (Fletcher 2020a).
When patients are cared for in bed it is recommended that the bed should be at a 30-degree tilt and pillows or wedges may be used for support and to maintain their position (Moore et al 2011). Pillows or wedges should also be used to prevent the knees or ankles from touching, reducing the risk of pressure and friction damage to those areas. Heels that show signs of erythema should be elevated, using pillows or wedges to prevent tissue damage (Black 2004). Many mattresses have a special ‘heel section’ which reduces pressure on this area further, although their effectiveness depends on the person’s heels remaining within that section. Inflatable or foam heel protectors can be used as an alternative (Rajpaul and Acton 2016).
A range of moving and handling equipment is available that aims to reduce shear and friction, including hoists, slings, glide and lock sheets, and slide sheets. Older, fragile skin can be easily damaged by equipment and/or inappropriate technique. Therefore, it is crucial that the appropriate technique is used with all moving and handling equipment to prevent injury to patients and staff (Fletcher 2020a). Nurses must be competent in operating any moving and handling equipment used in their organisation.
Evidence suggests that weight loss and inadequate nutritional intake are associated with a higher risk of developing pressure ulcers (Guenter et al 2000, Mathus-Vliegen 2001, Horn et al 2004). Unintentional weight loss is a major risk factor for malnutrition and pressure ulcer development (Kennerly et al 2015). Therefore, inadequate nutritional intake should be recognised, assessed and managed urgently. Examples of factors that can affect nutritional intake in older people are outlined in Box 1.
Medical factors
• Reduced appetite
• Inadequate dentition
• Dysphagia (difficulty swallowing)
• Oral health issues, for example oral thrush
• Loss of taste and smell
• Respiratory conditions, for example chronic obstructive pulmonary disease
• Neurological conditions, for example motor neurone disease
• Infection
• Physical disability, for example stroke
• Drug interactions
• Disease states, for example dementia or cancer
• Constipation
• Pain or discomfort
Lifestyle and social factors
• Inability to shop and/or cook
• Isolation or loneliness
• Poverty
• Lack of nutritional knowledge
• Lack of access to adapted cutlery
• Lack of assistance with feeding
Psychological factors
Organisational factors
• Requires assistance or supervision at mealtimes
• Insufficient time given to finish a meal at set mealtimes
• Missing dentures
• Inability to reach food, use cutlery or open packages
• Unpleasant sights, sounds and smells
• Increased nutrient requirements, for example due to infection
• Limited provision for religious or cultural dietary needs
• Nil by mouth or missed meals while undergoing investigations
(Adapted from Roberts et al 2019)
A validated malnutrition screening tool, such as the Malnutrition Universal Screening Tool (MUST) (Elia 2003), should be used for patients at risk of, or who have developed, a pressure ulcer (EPUAP et al 2019). Referral to a dietitian, speech and language therapist or occupational therapist may be necessary, for example to assess the need for a specialist diet and/or adapted eating utensils (EPUAP et al 2019).
Vitamins have a significant role in the prevention and management of pressure ulcers, particularly (Barchitta et al 2019):
• Vitamin A – this is essential for macrophage and monocyte stimulation, fibronectin deposition and cellular adhesion.
• Vitamin E – this is essential for its anti-inflammatory properties.
• Vitamin C – this is essential for collagen synthesis and strength, boosting the immune response and facilitating leukocyte migration.
• Zinc – this is an essential cofactor for normal cellular growth and replication, and directly influences epithelialisation, fibroblast proliferation and many immunologic responses, and supports phagocytosis and bactericidal activities.
Adequate hydration is essential for perfusion and oxygenation of, and delivery of nutrients to, tissues and cells and for the removal of waste products from cells via the renal system (British Dietetic Association 2019), so it is essential to ensure that older people have an adequate fluid intake. Pressure ulcers can produce high levels of exudate, so this loss of fluid needs to be replaced to prevent dehydration (Schols et al 2009).
Box 2 provides examples of management interventions to improve nutritional intake in older people.
• Treat medical conditions and/or review of medicines that could affect nutritional intake
• Modify or fortify foods and drinks, for example by adding cream or butter to foods, or offering smoothies that contain required nutrients
• Offer small regular meals with high-nutrient snacks provided in between meals
• Provide assistance with eating and drinking
• Make a referral to a speech and language therapist and/or an occupational therapist
• Provide a pleasant eating environment
• Allow sufficient time to eat
• Provide adapted cutlery
• Ensure optimal posture – this is particularly important for patients cared for in bed
• Ensure dentures are correctly fitted
• Monitor fluid intake and encourage regular, small drinks
• Offer counselling, advice and support or make a referral to the psychologist or mental health team if there are psychological causes of inadequate nutritional intake
(Adapted from Roberts et al 2019)
Urinary and faecal incontinence is common among older people with frailty (Spencer et al 2017). This can cause embarrassment, low self-esteem and social isolation, and without appropriate management may result in significant complications such as depression, falls and pressure ulcers (Aly et al 2020). However, managing continence issues is complex in this population due to potential comorbidities, polypharmacy and cognitive and functional impairment (Prud’homme et al 2018).
Managing continence issues should begin with a comprehensive assessment of the effects of the symptoms on the patient’s quality of life (Gibson and Wagg 2015) and should include a medication review. Management interventions in this population are supportive and behavioural-based, and may require considerable effort on the part of the older person, so should be considered within the context of their functional ability (Gibson and Wagg 2015). Examples of strategies for managing continence in older people are shown in Box 3.
• Provide support and encouragement to improve mobility
• Support the person to access the toilet regularly
• Reduce excessive fluid intake and encourage appropriate fluid intake
• Undertake a medication review
• Promote the use of continence products, for example pads, catheters, non-invasive urine collecting devices, faecal collectors and rectal tubes
• Monitor bowel action and treat constipation and/or faecal incontinence as appropriate
• Make referrals to other healthcare professionals, for example a continence nurse specialist
(Adapted from Spencer et al 2017)
If incontinence is not managed appropriately it may result in continence-associated dermatitis and lead to the development of pressure ulcers. Although continence-associated dermatitis is not a direct cause of pressure ulcers, it can affect the structure of the stratum corneum (the outermost layer of the skin), resulting in swollen, macerated, inflamed skin that is vulnerable to tissue breakdown and development of pressure ulcers (Fletcher 2020b). Normal skin pH ranges between 5 and 7, but the presence of urine means that the pH of the affected area becomes increasingly alkaline as the skin bacteria converts urea into ammonia, thus allowing microorganisms to multiply (Fletcher 2020b). Box 4 outlines an approach to preventing and managing continence-associated dermatitis.
Cleanse
• Use a pH-balanced cleanser to clean the skin after every episode of incontinence. If the skin is excoriated or broken, a foam cleanser may be appropriate as these products are pH balanced, gentle on the skin and remove faeces and urine without the need for excessive rubbing
• Avoid alkaline soaps
• If possible, use a soft non-woven disposable cloth or specialist continence wipes
Protect and restore
• Pat the skin dry – do not rub the skin
• Use moisturisers to help prevent skin from becoming dry or cracked, retaining optimum condition to withstand irritants such as urine and faeces. Moisturisers should replicate the skin’s pH level and should not contain fragrance or irritants
• The choice of barrier cream or ointment depends on the condition of the patient’s skin. If the patient uses continence pads, a water-based barrier product should be used to ensure that it does not compromise the effectiveness of the pad
(Adapted from Wounds UK 2018)
Development of pressure ulcers is a common and challenging issue in older people with frailty and can reduce people’s quality of life and increase mortality. Pressure is the main cause of pressure ulcers, while risk factors include age-related skin changes, immobility, inadequate nutrition and hydration, and continence issues, as well as comorbidities and polypharmacy. Prevention of pressure ulcers requires a multidisciplinary approach to the assessment, identification and management of risk factors. Nurses can reduce the risk of pressure ulcers in older people with frailty by supporting them to mobilise and through effective repositioning, while ensuring adequate nutritional and fluid intake and managing any continence issues.
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