Pressure sores are skin wounds resulting from unrelieved pressure which prevents blood from reaching vulnerable parts of the body. These sores may be made worse by friction- due, for example, to wet sheets, or by shearing stress such as occurs when a patient slides down the bed.

Known also as bed sores and decubitus (lying down) ulcers, these sores may also be caused by prolonged sitting. They take only a very short time to develop, sometimes only a few hours.

Normal pressure on the skin produces reddening which blanches when pressed. Pressure sores are characterised by reddening which does not blanch, and if the area of pressure is not relieved, a blister or break in the skin develops, which may be red, or black- indicating deeper damage. When any black, dead tissue breaks down, an open wound is created which may be deep, down even to underlying bone. Such dead tissue often becomes infected, but such infection clears up within a week or so, or once the dead tissue has been discharged. Full healing will take much longer with continuing pressure delaying this process.

Incidence

Depending on the population studied (whether living at home or in hospital, healthy or ill), the incidence has been estimated as being between 0.4% and 9%, the highest percentage being seen in hospital patients. Pressure sores increase in frequency with age, with the majority occurring in people over the age of 70.

The majority of sores are superficial, involving the skin only; only one in five is deep.

There are a number of common risk factors:

· Immobility, both of the whole body, due to illness and/or sedative drugs, and of parts of the body, due , for example, to stroke or hip fracture. Healthy people move frequently and unconsciously even in sleep.

· Acute illness such as pneumonia.

· Loss of sensation as in stroke or spinal cord injury.

· Incontinence and poor skin hygiene.

· Poor nutrition.

· Prolonged lying in bed or sitting in chairs.

· Other causes of pressure such as splints, bandages or ill-fitting shoes.

COMMON SITES FOR PRESSURE SORES

Most pressure sores occur over bony prominents in weight-bearing areas of the body. Almost one-third of all pressure sores occur in the lower spine, heels or sitting areas. Other less common sites are the hip bones, elbows, upper spine and knees.

Current thoughts on prevention

Pressure sores usually occur in individuals suffering from another illness and are, to a large extent, preventable. Therefore, the main emphasis must be on prevention and on the attention to detail required to achieve it. Identifying patients who require special care before pressure sores develop is essential.

Preventative measures include:
Reducing the length of time an older person stays in bed to the minimum.

Encouraging short excursions out of bed at the earliest possible opportunity.

Turning, lifting and re-positioning patients in bed every two hours or so to relieve pressure.

Protecting heels for short periods with heel protectors, for example immediately after a stroke. These become restrictive and uncomfortable if used over a longer period.

Special mattresses may be required if re-positioning is not possible or reddening of the skin develops. Portable large cell alternating pressure mattresses automatically change pressure points on the body and can be provided for home use by the GP or community nurse.

Take the weight off heels by using a bed cradle over the legs or lighter bed clothes.

Provide soft, clean and smooth sheets. Avoid plastic or abrasive surfaces and food crumbs.

Ensure sheets are dry, as skin hygiene is vital and barrier creams are of no real value. If incontinence is prolonged, consider the use of a catheter.

Individuals confined to a wheelchair and therefore immobilised in one position for long periods of time require the same attention. Correct posture, regular movement to take the weight off the bottom every 15 minutes, and proper cushions prescribed by an occupational therapist for wheelchairs are all effective preventive measures.

Current thoughts on treatment

If a pressure sore develops, ensure the same steps as listed above are taken, paying particular attention to the relief of pressure. If the skin is unbroken, these measures alone may encourage healing. If the skin is broken, the wound will need to be dressed. A range of special dressings is available and will be supplied by the community nurse. Surgery may occasionally be required for large sores, particularly for patients with spinal cord damage.

In all cases, strict attention must be paid to prevention to ensure sores do not reappear.

Where to get help

Talk to your GP first of all. He or she will refer you to the community nurse who will advise on the best treatment.

The need for research

Pressure sores are extremely common, particularly in vulnerable older people after illnesses such as stroke or hip fracture, despite the fact that they are largely preventable. Once they occur they take a long time to heal. It is essential, therefore, that health professionals and carers understand the need for strict attention to prevention, and are trained as necessary to implement these measures.