Pressure Sores: A Silent Threat to the Elderly

Depressed senior man lying in bed cannot sleep from pressure sores

There’s a reason why we so often see the term “bed sores” at the top of the list of things we should be concerned about when an elderly family member is in a long-term care facility or hospital. According to the National Pressure Injury Advisory Panel (NPIAP), statistics show that about 2.5 million patients develop bed sores each year, leading to an astonishing 60,000 deaths from such injuries.

Also known as pressure sores or pressure ulcers, bed sores are skin wounds that occur when someone remains in the same position for too long, such as when a person is bedridden or spends a significant portion of their day confined to a wheelchair. While a skin irritation caused by simply not moving may sound like a fleeting condition that is uncomfortable at worst, the reality is that bed sores can lead to very serious – and even deadly – complications very quickly, particularly for the elderly who are prone to long periods of immobility and whose frail skin offers much less protection than it did when they were younger.

As with any medical condition, prevention is always better, so family caregivers and medical professionals need to be knowledgeable and vigilant about warning signs and risk factors. If the sores have already formed, adequate treatment is crucial and dependent on the severity of the wound.


How Do Pressure Sores Develop?

The human body is designed to be in constant motion. Even while we sleep, we shift positions in bed, or while we’re sitting, we’re constantly readjusting ourselves. This is of course second nature, but as we get older and our bodies become weaker and less agile, the intuitive act of moving around and “getting the blood flowing” will start to seem more and more like a luxury.

When a person is immobile for extended periods of time, pressure sores can form in the areas of the body that have the least amount of padding of muscle and fat, particularly over a bone (i.e. a hip or an elbow). The pressure that is put on the tissue between the bone and the surface of a bed or wheelchair cuts off the blood supply and deprives the tissue of oxygen and nutrients. This lack of circulation can damage the underlying tissue and essentially cause the skin to die, leading to an irritation, which can quickly turn into an open wound.

The three most common ways in which this type of skin damage occurs are through:

  • Pressure from total immobility when sitting or lying for too long (even as little as 12 hours) without shifting position.
  • Friction that can occur when a caregiver moves a body, for example, from a bed to a wheelchair or vice versa. Even though, as previously mentioned, frequent changes in position are essential to preventing bed sores, this type of movement or rubbing can have the adverse effect, damaging the skin if the caregiver doesn’t handle these transfers delicately.
  • Shearing that is caused by slowly sliding or slumping down in a bed or chair over time. This makes the skin slide in the direction opposite of the bone and supportive tissue, which can lead to stretching and tearing.

Most doctors agree that pressure is the most common cause of these types of wounds (hence the blanket term “pressure sores”), and it’s only logical that senior citizens, many of whom have severe mobility issues, are at a much higher risk, especially when taking into account the fact that skin becomes thinner, loses elasticity, and becomes much more fragile with age.


Risk Factors Among the Elderly

There are a myriad of risk factors putting the elderly at a disadvantage when it comes to bed sores. Common problems such as arthritis can make movement painful or even impossible. Patients who are bedridden because of a recent surgery or people who are paralyzed will be unable to move their bodies even slightly to increase blood flow to compressed areas.

Perspiration from fevers or excess moisture from incontinence can also affect the skin – making it weaker and more prone to irritation. Other risk factors and chronic health conditions that are common among seniors and that can affect circulation, mobility, and/or sensory perception include:

  • Cancer
  • Stroke
  • Multiple Sclerosis
  • Parkinson’s disease
  • Alzheimer’s disease
  • Dementia
  • Diabetes
  • Malnutrition
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Peripheral Artery Disease (PAD)
  • Heart failure
  • Hip fractures
  • Urinary or fecal incontinence
  • Smoking

Caregivers and medical professionals with patients who are suffering from any (or a confluence) of the aforementioned conditions should be extra attentive and have a keen eye for what to look for if pressure ulcers start to develop.


Warning Signs of Pressure Sore Development

Early detection is very important, especially when dealing with elders because what may seem like a mild skin irritation in the beginning can quickly develop into a painful open wound. Without the proper intervention and skin care procedures, these dreaded wounds can become dangerously deep and infected.

Early signs of pressure sores appear on the surface of the skin and may be subtle, so family members and caregivers should be inspecting their patients regularly for the following warning signs:

  • Variations in skin color: An irritation to the skin will initially manifest itself through a change in color. Patients with lighter skin may exhibit red or pink marks and patients with darker skin may exhibit blue or purple marks.
  • Changes in skin temperature: If the skin feels unusually warm, it could be a sign of an inflammation. Conversely, if it feels unusually cool, it might mean that there is little or no blood flow to the affected area. Both of these could be signs of a developing bed sore.
  • Changes in skin texture: The affected area may feel soft, or spongy to the touch. It may also feel hard, flaky, or ashen, in contrast to surrounding areas.
  • Odd sensations in affected area: The patient may feel burning, itching, tingling, numbness, or pain in certain parts of their body.
  • Bruising: If an elder falls and develops a deep bruise over an area of the body that is prone to pressure sores, it should be closely monitored because the already damaged tissue can quickly turn into a sore or a wound.


What Parts of the Body Develop Pressure Sores?

The areas of the body that are most vulnerable to pressure sores will depend on whether the patient in question spends most of their time lying down or sitting down (or both).

If the patient is bedridden, the most common sites for bed sores are:

  • Coccyx (tailbone)
  • Sacrum (bone at the base of the spine, above the tailbone)
  • Hipbones
  • Heels of feet
  • Elbows
  • Shoulders and shoulder blades
  • Areas of the head (such as the ears) that touch the bed surface or pillow

If the patient is in a wheelchair, the highest risk areas are:

  • Tailbone and buttocks
  • Backs of arms and legs where they touch the chair
  • Along the spine (where vertebrae protrude)
  • Part of the pelvis that supports a person while sitting (known as the ischial tuberosity)


Prevention of Pressure Sores

Now that you know which parts of the body to keep an eye on, regular inspection of these areas to ensure that they’re not exhibiting any discoloration or other warning signs is half the battle when preventing pressure sores.

Beyond that, doctors recommend the following practices to ensure that bed sores are kept in check:

  1. Repositioning regularly: Ideally, the body should be repositioned at least every 2 hours in bed, and every 30 minutes in a wheelchair. Depending on the patient, the movement can be achieved by alternating between standing and sitting, or moving from one side of the bed to the other. Other circumstances should also be taken into account, such as if a patient is recovering from surgery and needs rest, the repositioning should try to be done in a way that doesn’t wake them up every two hours.
  2. Protecting vulnerable areas: Legs can be supported with a foam pad or pillow, special mattress overlays can be placed over the regular mattress for additional cushioning, chairs and wheelchairs can be padded with cushions. In terms of materials (such as foam, gel, air, etc.) it’s important to consult an expert and/or research pressure sore prevention products because some may cause more harm than good depending on the application and the patient’s needs.
  3. Cleaning skin gently and keeping it lubricated: When bathing a senior, use mild soaps and warm water and avoid harsh motions such as scrubbing and rubbing. Dry off skin to keep it free of moisture. However, overly dry skin can be problematic as well, so using the right lotions and creams to keep skin from cracking will make it more resilient.
  4. Providing a healthy, balanced diet: Meals should contain enough protein and a good variety of vitamins and minerals. The best diet will vary from patient-to-patient. If a patient is too thin, the lack of body fat and muscle mass will make them more prone to pressure sores, so a higher caloric intake should be considered. Conversely, obesity can put too much stress on the body’s pressure joints, so diets should be calibrated accordingly so that each patient can maintain a healthy weight.


Pressure Sore Stages and Treatment

Oftentimes, bed sores are very challenging to treat because many of the conditions that caused them in the first place (such as immobility, diabetes, or thin, weak skin) will make them exponentially worse over time. For this reason, it’s extremely important to know the appropriate course of treatment depending on the severity of the wound.

The four major stages of pressure sores are classified as follows:

Stage I – Pressure Sores

Symptoms: The skin is intact but has changed in color, temperature, and/or texture. Pain, burning, or itching are common symptoms. When pressed on, the spot doesn’t get lighter in color, meaning less blood is getting to the area. This is the mildest stage and only affects the upper layer of your skin.

Treatment: Prompt and consistent repositioning to relieve pressure from the sore is the most important step. Gentle cleansing and moisturizing the skin with lotion will also help protect it against excess moisture and bacteria.

Stage II – Pressure Sores

Symptoms: The skin breaks and forms an open wound, a shallow ulcer with pink tissue in it, or a pus-filled blister. The area may be warm and swollen, is painful, and may ooze a clear fluid, blood, or pus.

Treatment: Affected area should be cleaned with a saltwater rinse or a cleanser recommended by a healthcare provider. The sore may be covered with a transparent, semi-permeable dressing or moist gauze. Topical antibiotics, gels, or creams may also be applied and covered with gauze.

Stage III – Pressure Sores

Symptoms: Characterized by a deeper ulcer that looks like a crater and may have a bad odor (by this stage, the sore has gone through the second layer of skin and permeated the fat tissue). Visual signs of infection can include red edges, a thin scab, yellow “slough” tissue, pus, odor, or heat.

Treatment: This stage requires a more advanced level of treatment. The ulcer should be kept moist and the same gels and creams used to treat stage 2 wounds may be effective as well. However, a doctor may need to remove any dead tissue and prescribe antibiotics to fight an infection. The ulcer may also need to be packed if the wound is deep. Special beds or mattresses and other pressure-reducing support surfaces should also be utilized, many of which are covered by insurance.

Stage IV – Pressure Sores

Symptoms: The sore is big, deep, and extends down to the bone, tendon, or muscle (which may be visible at this stage). Skin may have turned black and shows obvious signs of infection (discolored edges, pus, heat, odor, and/or drainage). Eschar (dead tissue), slough, scab may also be present.

Treatment: These wounds need immediate attention and may require surgery. A process called debridement is often used to clean out dead tissue with a scalpel or scissors, which needs to be performed by a professional. If the wound is deep near the intestines or other vital organs, surgery is most likely required. After the necessary immediate procedures are performed, it should be treated like a stage 3 wound.

Other Stages

Aside from the four most common stages, two other categories can include:

Unstageable pressure sore: With this type of wound, you can’t see the bottom of the sore or know how deep it is because it is covered by eschar or a scab. In this case it’s unclear if the sore is stage 3 or stage 4, and needs to be cleaned out by a doctor to stage it accordingly.

Suspected Deep Tissue Injury (SDTI): These display symptoms of a stage 1 or stage 2 sore on the surface (discoloration, change in temperature or texture) but are actually a stage 3 or stage 4 injury beneath the surface. These are dangerous because they can develop into high stage ulcers quickly, and require close monitoring and constant pressure relief to ensure that the deep wound doesn’t open to the surface or becomes infected.


Pressure Sores & Elder Abuse in Nursing Homes

If the required preventative measures and proper protocol for treating pressure sores aren’t followed in a nursing home or long-term care facility, this means that the institution is failing to provide proper care, which is a dangerous form of elder abuse. Neglect on the part of nursing home staff should be investigated and legal action can be taken on behalf of the injured individual.

At Berberian Ain, LLP you can count on our elder abuse attorneys for dedicated and skilled legal support on this matter. We adhere to California’s Elder Abuse and Dependent Adult Civil Protection Act and will fight for justice on your behalf. If you or a loved one has been on the receiving end of improper care or attention when it comes to pressure sores, contact Berberian Ain LLP today or call 818-808-0048 to schedule a free initial consultation with one of our lawyers.