Drugs Aging 2010; 27 (4): 311-325

REVIEW ARTICLE 1170-229X/10/0004-0311/$49.95/0

ª 2010 Adis Data Information BV. All rights reserved.

Assessment and Management of

Pressure Ulcers in the Elderly
Current Strategies
Efraim Jaul1,2
1 Skilled Geriatric Nursing Department, Herzog Hospital, Jerusalem, Israel
2 Hebrew University Hadassah Medical School, Jerusalem, Israel

Contents
Abstract. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 312
1. Risk Factor Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
1.1 Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
1.2 Co-Morbidities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
1.3 Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
1.4 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 315
1.5 Social, Family and Emotional Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
2. Wound Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
2.1 Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 316
2.2 Staging. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
2.3 Surface Appearance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
2.4 Infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
2.5 Odour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
2.6 Exudate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
2.7 Pain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
2.8 Undermining . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
2.9 Surrounding Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
3. Pathogenesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
3.1 Extrinsic (External) Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
3.2 Intrinsic (Internal) Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
4. Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
4.1 Stabilization and Cure of Reversible Medical Conditions and Treatment of Irreversible
Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
4.2 Preventing and Minimizing Complications of the Dysfunctional Status. . . . . . . . . . . . . . . . . . . . . . 319
4.3 Provision of Food and Fluids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
4.4 Local Wound Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
4.4.1 Debridement and Cleaning. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
4.4.2 Dressings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321
4.4.3 Pressure Relief Devices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
4.4.4 Local Agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
4.4.5 Surgical Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
4.4.6 Complementary Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
4.5 Family Support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 322
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
312 Jaul

Abstract Pressure ulcers (pressure sores) continue to be a common health problem,

particularly among the physically limited or bedridden elderly. The problem
exists within the entire health framework, including hospitals, clinics, long-
term care facilities and private homes.
For many elderly patients, pressure ulcers may become chronic for no
apparent reason and remain so for prolonged periods, even for the remainder
of the patient’s lifetime. A large number of grade 3 and 4 pressure ulcers
become chronic wounds, and the afflicted patient may even die from an ulcer
complication (sepsis or osteomyelitis).
The presence of a pressure ulcer constitutes a geriatric syndrome consisting of
multifactorial pathological conditions. The accumulated effects of impairment
due to immobility, nutritional deficiency and chronic diseases involving multiple
systems predispose the aging skin of the elderly person to increasing vulnerability.
The assessment and management of a pressure ulcer requires a comprehen-
sive and multidisciplinary approach in order to understand the patient with the
ulcer. Factors to consider include the patient’s underlying pathologies (such as
obstructive lung disease or peripheral vascular disease), severity of his or her
primary illness (such as an infection or hip fracture), co-morbidities (such as
dementia or diabetes mellitus), functional state (activities of daily living), nu-
tritional status (swallowing difficulties), and degree of social and emotional
support; focusing on just the wound itself is not enough. An understanding of
the physiological and pathological processes of aging skin throws light on the
aetiology and pathogenesis of the development of pressure ulcers in the elderly.
Each health discipline (nursing staff, aides, physician, dietitian, occupational
and physical therapists, and social worker) has its own role to play in the as-
sessment and management of the patient with a pressure ulcer. The goals of
treating a pressure ulcer include avoiding any preventable contributing circum-
stances, such as immobilization after a hip fracture or acute infection. Once a
pressure ulcer has developed, however, the goal is to heal it by optimizing re-
gional blood flow (by use of a stent or vascular bypass surgery), managing
underlying illnesses (such as diabetes, hypothyroidism or congestive heart fail-
ure) and providing adequate caloric and protein intake (whether through use of
dietary supplements by mouth or by use of tube feeding). If the ulcer has become
chronic, the ultimate goal changes from healing the wound to controlling symp-
toms (such as foul odour, pain, discomfort and infection) and preventing com-
plications, thereby contributing to the patient’s overall well-being; providing
support for the patient’s family is also important. Recent advances in wound
dressings allow for greater control of symptoms and prevention of complica-
tions, and have also enabled the affected patient to be integrated more readily
into the family setting and in the community at large. Ethical and end-of-life
issues must also be addressed soon after the wound has become chronic.
This article discusses the pathogenesis of pressure ulcer development in the
elderly in relation to concomitant diseases, risk factor assessment and the
management of such ulcers.

Pressure ulcers (pressure sores, bedsores) are a There has been an increase in the prevalence of
common problem among the elderly in hospitals, pressure ulcers in recent years.[4,5] Increased life
long-term healthcare facilities and at home. They re- expectancy in the overall population has resulted
duce quality of life and can even be life threatening.[1-3] from solutions being found for many geriatric

ª 2010 Adis Data Information BV. All rights reserved. Drugs Aging 2010; 27 (4)
Pressure Ulcers in the Elderly
illnesses but has also exposed other dormant
medical problems, especially in the ‘old-old’.[6]
Advancing chronological age increases exposure
to pathological factors that develop as a result of
biological aging. Modern medicine has trans-
formed many acute diseases to chronic condi-
tions, allowing patients to live longer even when
these chronic conditions are severe.[7] As a con-
sequence, debilitated patients with severely lim-
ited daily functioning are living increasingly
prolonged lives, sometimes by artificial means.[8]
Early intervention is emphasized as a pre-
ventative procedure for bedsores. When elderly
patients are confined to bed at the onset of an
acute illness and shortly after hospital admission,
pressure ulcers are prone to develop as a result of
a lack of repositioning or failure to use pressure-
reducing devices.[9-11] In one study, 30% of elderly
patients with hip fracture developed pressure ul-
cers shortly after hospital admission.[12]
The natural course of a pressure ulcer in an
elderly patient is difficult to predict. For no ap-
parent reason, many patients become ‘stuck’ with
a pressure ulcer at a certain stage for prolonged
periods and sometimes for the remainder of their
lives. A large number of grade 3 and 4 pressure
ulcers become chronic wounds.[13,14] An elderly
patient may live for a long time with a bedsore,
and may even die from a complication of the ul-
cer (sepsis or osteomyelitis).[15] Even in the best of
circumstances, when the wound has been cured,
it may recur if the underlying contributing risk
factors, such as immobility, persist.
Many factors act synergistically to cause pressure
ulcers. The first potential risk factor is the process of
aging of the patient’s skin.[16,17] The second risk
factor is the pathology and structural impairment
associated with a disease that is undermining the
physiological infrastructure of the skin. The third
contributing factor is malnutrition as part of a
chronic disease that reduces muscle mass, thins the
skin and reduces immunocompetence.[18] However,
the most significant risk factor is the functional
outcome of disease, including immobility, incon-
tinence and impaired cognition. These functional
impairments, particularly immobility, increase the
vulnerability of the skin to extrinsic factors, such as
pressure, shearing forces, friction and wetness, that
ª 2010 Adis Data Information BV. All rights reserved.
313
reduce the integrity of the skin tissue and result in
development of pressure ulcers.[19]
Pressure ulcers reflect a geriatric syndrome in
which multifactorial pathological conditions are
present and the accumulated effects of impair-
ment of multiple systems aggravate the vulner-
ability of the older person to development of
these ulcers. Multiple aetiological factors inter-
acting in pathogenetic pathways cause a single
manifestation, e.g. a pressure ulcer.[20]
Assessment and management of pressure ulcers
require a comprehensive and multidisciplinary ap-
proach in order to understand the patient ‘behind’
the ulcer. Such an assessment should take into
account the patient’s underlying pathology and
severity of primary illness, co-morbidities, func-
tional state (activities of daily living), nutritional
status, and social and emotional support, rather
than focus on the wound alone. Each health
discipline (nursing staff, aides, physician, dietitian,
occupational and physical therapists, and social
worker) has its own role to play in helping patients
overcome pressure ulcers.[21] Therefore, the com-
prehensive geriatric approach focuses on symptom
control, prevention of complications, emotional
support, family involvement and the patient’s
overall well-being, as well as on healing the ulcer.
This review discusses the pathogenesis of pres-
sure ulcer development in the elderly, the im-
portance of considering concomitant diseases and
other risk factors, and the management of pressure
ulcers. Connecting the pressure ulcer to the person
as a whole is emphasized throughout the review.
1. Risk Factor Assessment
Assessment of pressure ulcers should comprise
both a local evaluation of the wound and a sys-
temic assessment of the patient. The status of a
pressure ulcer reflects the patient’s overall physi-
cal and functional status; the appearance of
pressure ulcers in a frail elderly person often in-
dicates a poor prognosis.[22,23]
1.1 Aging
The potential risk of developing a pressure ulcer
in the elderly population increases exponentially
Drugs Aging 2010; 27 (4)
314
with age:[24] 70% of pressure ulcers occur in
people aged >70 years.[25] The aging process and
environmental factors damage the skin and in-
crease the likelihood of developing pressure ulcers.
Age-related skin changes are indicated by flatten-
ing of the dermo-epidermal junction and slow
turnover of skin cells, loss of elasticity, thinning of
subcutaneous layers, reduction of overall muscle
mass (sarcopenia), and decreased intradermal vas-
cular perfusion and oxygenation.[26,27]
The physiological healing process of wounds
consists of four dynamic, well defined, overlapp-
ing stages: haemostasis, inflammation, prolifera-
tion and remodelling.[28] In aging individuals, the
healing process might be arrested at any of these
stages, and particularly at the inflammatory or
proliferative stage. The mediators of this arrest
can include impairment of inflammatory cells,
growth factors, proteases, cellular and/or extra-
cellular elements.[29] A low level of activity of
the inflammatory cells and growth factors, with
resultant slowing of the migration of macro-
phages, may result in arrest at the inflammatory
stage.[30] The levels of platelet-derived growth
factor and transforming growth factor are also
significantly reduced. Angiogenesis in the wound
is significantly delayed and re-epithelialization is
slower than in younger patients. On the other
hand, the level of activity of the matrix metallo-
proteinases, which break down intercellular
structural proteins, is greatly increased in the
elderly and may result in arrest at the prolifer-
ative stage.[31]
1.2 Co-Morbidities
Physiological changes in older people lead to a
decrease in bodily reserves, making the body
vulnerable to disease. Superimposed on normal
aging are pathological processes that impel the
individual into acute illness, which in turn results
in the collapse of diverse systems such as skin
tissue. This collapse is similar to a domino effect,
leading to the development of pressure ulcers and
potentially to multisystem failure.[32]
Acute disease often demands a period of bed
rest that may well predispose to and increase the
risk of developing pressure ulcers. However, there
ª 2010 Adis Data Information BV. All rights reserved.
Jaul
may not be sufficient awareness of the risks
associated with temporary immobility, e.g. ‘decon-
ditioning’ of the muscle, which occurs commonly
after falls, hip fracture, surgery and infection.[33]
These conditions increase the likelihood of devel-
opment of pressure ulcers as a result of patients
not being able to reposition themselves.[34,35]
The high prevalence of many systemic chronic
illnesses or disease states in the elderly contri-
butes to pressure ulcers.[35] Arterial insufficiency
may cause ischaemia by arteriosclerosis, the
‘watershed’ effect and vascular steal syndrome.
Venous insufficiency and chronic lymphoedema
impair fluid return from the lower limbs. Multi-
ple sclerosis, diabetes mellitus and stroke can
cause sensory deprivation. Congestive heart, liver
or kidney failure may cause chronic oedema.
Neurological disease of the CNS such as demen-
tia or Alzheimer’s disease may cause agitation and
friction. Cancer and other terminal conditions
impair immunocompetence. Parkinson’s disease,
antipsychotic drugs and dementia increase the
risk of spasticity. Dehydration can cause skin
dryness; high temperature, fever and urinary in-
continence cause skin wetness. Medications used
to treat chronic diseases may have adverse effects
such as bladder dysfunction, reduced blood
pressure, rigidity, sedation, confusion, drowsi-
ness and constipation. All of these systemic dis-
eases or states make the skin more vulnerable to
becoming ulcerated and, thereby, more prone to
developing a pressure ulcer.[36]
1.3 Function
The outcomes of advancing disease may be
severe disability, including immobility, inconti-
nence and impaired cognition.[37] These disabilities
contribute to the development and persistence of
pressure ulcers, notably when combined with an
underlying co-morbidity.
Immobility is the most significant risk factor
for the formation of pressure ulcers.[38] Other risk
factors evaluated as part of the functional assess-
ment of patients with pressure ulcers include
extrinsic causes such as shearing and direct pres-
sure forces and intrinsic factors resulting from
co-morbid diseases.[39]
Drugs Aging 2010; 27 (4)
Pressure Ulcers in the Elderly
Immobility in the elderly is the inability to
change the position of the body, or part of it,
without help. It may be caused by depression of
the CNS, as in the case of the vegetative state,
extensive stroke or end-stage dementia, and may
be complicated by an accompanying sensory im-
pairment. Mild stroke, advanced diabetes and
spinal injury affecting part of the body, such as
hand paralysis whereby the patient is unable to
grasp the bed side-rails and turn him- or herself,
may give rise to pressure ulcers because of a lack
of movement.
Physical or chemical restraints sometimes used
in delirious elderly patients can cause motor or
sensory impairment. Chemical restraints may
lead to sensory deficiencies as a result of sedative
and hypnotic medication use, resulting in sleepi-
ness and loss of awareness. Physical restraints
may lead to motor limitations, resulting in abra-
sions, injuries and breakdown of the skin. In
addition, other functional impairments such as
urinary or faecal incontinence or cognitive impair-
ment disrupt the integrity of the skin by causing
wetness and lack of awareness, respectively.[40]
At the onset of an acute illness and at the time
of admission to a hospital or other medical fa-
cility, every elderly patient requires risk assess-
ment to identify the risk of pressure ulcers. The
most widely used and recognized risk assessment
scales are the Norton, Braden and Waterlow scales,
all of which measure risk quantitatively.[41-43]
The Norton scale score ranges from 5 to 20
points.[41] It assesses five risk-based items: physi-
cal condition, mental condition, activity, mobil-
ity and continence. A score of £14 is considered
high risk. The Braden scale score ranges from 6 to
23 points and assesses risk according to six fac-
tors: sensory perception, skin moisture, activity
levels, mobility, observed nutritional intake, and
friction and shearing forces.[42] A score of £16 is
considered high risk. The Waterlow scale assesses
eight items: body build (weight and height),
visual evaluation of the skin, sex and age, con-
tinence, mobility, appetite, medication and spe-
cial risk.[43] The potential for risk occurs with a
score between 10 and 14 points.
Of these scales, the Braden scale was found
to have the best sensitivity and specificity, i.e.
ª 2010 Adis Data Information BV. All rights reserved.
315
57.1% and 67.5%, respectively, with a risk ratio of
4.08.[44] The Norton scale had 46.8% sensitivity
and 61.8% specificity, with a risk ratio of 2.16.
The Waterlow scale had 82.4% sensitivity and
27.4% specificity, with a risk ratio of 2.05. Nur-
ses’ clinical judgment had 50.6% sensitivity and
60.1% specificity, with a risk ratio of 1.69. Al-
though high in sensitivity and specificity, the
scales taken together had a modest positive pre-
dictive value of 37%, but this was still greater
than nurses’ clinical judgement.[44]
1.4 Nutrition
Pressure ulcers and impaired nutrition often
co-exist in the frail elderly, whether hospitalized
or living in a long-term care setting.[45] There is a
strong correlation between poor nutritional sta-
tus and the development of pressure ulcers.[46]
The appearance of pressure ulcers reflects a
catabolic state accompanied by protein con-
sumption, resulting in muscle wasting and tissue
destruction.[47]
Every elderly patient should be regarded as at
risk for malnutrition because of physical, social
or mental conditions. Malnutrition often begins
with protein energy malnutrition, a condition
that is frequently seen in elderly persons in nur-
sing home facilities and hospitals as well as at
home.[48]
Nutritional assessment involves taking a his-
tory from the patient or the family regarding food
intake, particularly with regard to protein and
total calorie consumption and weight loss. A
history of digestive problems (e.g. nausea, con-
stipation, diarrhoea and/or vomiting) should be
noted. The state of dentition should be evaluated,
including chewing and swallowing ability. Im-
paired functional ambulation and hand and fin-
ger skills should be identified. Other important
contributing factors include social isolation, lack
of nearby family accessibility and poverty.[49]
Awareness on the part of the physician of all
medications being taken, particularly those that
can cause digestive problems, reduce appetite,
cause constipation and bring about dryness of the
mouth, is of primary importance.[50] Dietary re-
strictions on eggs and meats, which are good
Drugs Aging 2010; 27 (4)
316
sources of protein, should be abandoned in these
cases. Depression and dementia and other neuro-
logical disorders require mental and neurological
examination.
Bedside assessment of swallowing ability is an
examination that is too often overlooked by the
physician and nurse and its importance must be
emphasized. A speech therapist can be valuable
in recommending a given food texture or fluid
density in situations where either eating or
drinking ability is limited.[51]
The Subjective Global Assessment (SGA)
scale is an effective clinical nutrition assessment
tool.[52] The SGA measures four items: the per-
centage of weight lost in the previous 6 months;
gastrointestinal complaints; loss of subcutaneous
fat; and reductions in muscle tissue. Another
malnutrition risk assessment tool used for elderly
patients is the Mini Nutritional Assessment
(MNA) Short Form, which measures body mass
index, involuntary loss of weight in the previous
3 months, acute disease in the previous 3 months,
mobility, the presence of neuropsychological
diseases and loss of appetite in the previous
3 months.[53]
Anthropometric measurement as part of nu-
tritional assessment focuses on the triceps skin
fold, mid-arm circumference, atrophy of muscles
and presence of oedema. Accompanying these
assessments are measurements of laboratory
markers (albumin, haemoglobin, cholesterol and
total lymphocyte count) that reflect the existing
nutritional status and often tend to highlight the
acute physical state.[54]
1.5 Social, Family and Emotional Factors
It is possible for a pressure ulcer to not heal
and become chronic. This unanticipated clinical
course of the ulcer leads to frustration for pa-
tients and their families, and increases emotional
upset. Social workers need to assess the family
support networks and community resources of
the patient and family. The accompanying econ-
omic burden resulting from the pressure ulcers
also has to be assessed.[55]
The chronicity of a pressure ulcer results in
symptoms and other sequelae, such as pain, dis-
ª 2010 Adis Data Information BV. All rights reserved.
Jaul
comfort, diminution of quality life, cognitive im-
pairment and reduced competence, that require
periodic assessment. End-of-life issues may arise,
such as the advisability of amputation or exten-
sive surgical debridement, admission to a nursing
home or the declaration of the patient as DNR
(do not resuscitate). Thus, the family should be
provided with realistic expectations about the
situation. The family’s wishes should be respected
whenever possible, especially when the patient is
no longer competent to make decisions on his or
her own behalf.[56]
2. Wound Assessment
Wound assessment comprises evaluation of
a number of parameters: site, staging (depth),
surface appearance (colour), infection, odour,
exudate, pain, undermining (of the soft tissue)
and the condition of the area surrounding the
wound.[57,58]
2.1 Site
The typical ‘hot spots’ for pressure ulcers are
where bony prominences underlie soft tissues. The
majority of bedsores occur in the lower trunk,
over the sacrum and coccyx (tailbone), ischium,
gluteal muscles (buttocks) and greater trochan-
ters (hips). The location of pressure ulcers may
provide insight into their cause. For example,
excessively prolonged sitting and lack of re-
positioning should be suspected if the wound is
located overlying the ischial tuberosities. Heel
ulcers occur in sedentary patients and indicate a
possible component of arterial insufficiency.
There are also atypical locations for pres-
sure ulcers that may point to underlying bony
malformations, such as winged scapula or ky-
phosis. Another unusual causative factor for
pressure sores is insertion of tubes into the pa-
tient for therapeutic reasons. Indeed, pressure
ulcers may be caused by tubes either at the
point of insertion or anywhere along the course
of the tube. A pressure ulcer in the nostril at the
point of entry of a nasogastric tube is commonly
seen. Another common example is an ulcer of
the glans penis next to an indwelling urinary
Drugs Aging 2010; 27 (4)
Pressure Ulcers in the Elderly
catheter, at the urethral opening. The tape that
binds a tracheostomy tube to a patient also can
cause a bedsore on the back of the neck. Wrinkles
in bed sheets or clothing may also cause pressure
ulcers.
2.2 Staging
There are four stages of bedsores:[59]
 Stage I consists of intact skin with non-
blanching erythema.
 Stage II is marked by partial skin-thickness
damage or loss, involving epidermis and/or
dermis, including blisters and abrasions.
 Stage III is described by a full-thickness skin
loss with damage to subcutaneous tissue, but
not deeper than the underlying fascia.
 Stage IV includes extensive destruction of
underlying tissue, including muscle and possi-
bly bone and supporting structures.
A recent official revision of the staging system
by the National Pressure Ulcer Advisory Panel
(NPUAP) added the categories of an unstageable
state and deep tissue injury.[60] The unstageable
category is identified as a surface covering of ne-
crotic tissue, slough or eschar, with depth ob-
scuration. Deep tissue injury is defined by injury
to subcutaneous tissues under intact skin. It in-
itially appears as a discolouration or bruising of
the skin, later progressing to a deep pressure
ulcer.
2.3 Surface Appearance
The surface of a pressure ulcer may be de-
scribed as viable, with a bright red colour; this
reflects granulation and proliferation of new
vessels (neovascularization), leading to healing.
A dark red colour may be indicative of local in-
fection or bleeding. Pieces of bone may be extrac-
table from deeper bedsores. Over-granulation
may be due to infection and non-healing.
Necrotic tissue is a non-viable tissue; slough is
dead tissue, usually cream-coloured or yellow;
and eschar is a black, hard crust overlying the
wound. It is difficult to determine the stage
(depth) of a wound with overlying eschar, slough
and necrotic tissue, and this presentation is
therefore termed unstageable (see section 2.2).
ª 2010 Adis Data Information BV. All rights reserved.
317
2.4 Infection
The classic manifestations of infection, such as
redness (rubor), pain (dolor), heat (calor) and
swelling (turgor), apply also to bedsores, as do
foul odour, bleeding and purulent exudates. Any
or all of these features may be found, particularly
in a non-healing pressure ulcer. Every bedsore is
colonized by bacteria and, therefore, needs rou-
tine cleaning. However, there is no justification
for bacterial culture of the surface except when
the bedsore involves bone, has formed an abscess
or is a non-healing wound. Systemic administra-
tion of antibacterials, selected on the basis of
antibacterial susceptibility, is then warranted.
2.5 Odour
The presence of necrotic tissue or a severe in-
fection is often accompanied by a foul odour,
particularly in the presence of anaerobic bacteria.
These foul odours may disturb the patient and
those in the immediate vicinity. The proper
treatment includes surgical (sharp) debridement,
thorough cleaning and appropriate application
of dressings containing absorbent and charcoal
ingredients.
2.6 Exudate
Pressure ulcers often exude (secrete) serous,
bloody or purulent liquid in varying amounts. In
the case of excessive secretion, an active infection
should be suspected. These exudates, particularly
if serous, may accompany the oedema surround-
ing a bedsore and predispose to superimposed
infections.
2.7 Pain
A pressure ulcer may cause pain continuously
or intermittently. Intermittent pain may occur
during local treatment and dressing changes.
Continuous pain is characteristic of neuropathy,
ischaemia, oedema and/or infection.
2.8 Undermining
Undermining of the soft tissue underlying a
pressure ulcer is often manifested by pockets of
Drugs Aging 2010; 27 (4)
318
pus (abscesses). These pockets must be opened
and drained in order to facilitate healing. There is
no justification for administering systemic anti-
bacterials without first properly draining these
abscesses. The importance of bluntly probing an
abscess, whether with a (gloved) finger or me-
chanical probe, cannot be overemphasized.
2.9 Surrounding Area
The skin area surrounding a pressure ulcer
may be either macerated or infected. It may be
macerated because of excessive wound exudates
and the relative inability of the dressing to absorb
the secretion. In addition, cellulitis and eczematous
or callosities should be identified and treated.
3. Pathogenesis
The pathogenesis of pressure ulcers is tradi-
tionally divided into local and systemic factors.
Geriatricians view these risk factors in terms of
‘intrinsic’ (internal) and ‘extrinsic’ (external) fac-
tors. Local factors relating to the wound, such as
hypoxia, inadequate vascular supply and infec-
tion, reflect systemic, intrinsic processes that af-
fect pressure ulcers.[61]
3.1 Extrinsic (External) Factors
The four most common extrinsic (external)
physical forces that cause pressure ulcers are
interface (axial) pressure, shearing (tangential)
pressure, friction and excessive moisture.[62,63]
Interface (axial) pressure causes a decrease in
capillary blood flow and occlusion of blood per-
fusion to the local territory, which is followed
by tissue ischaemia. The average intravascular
capillary pressure is 32 mmHg; sitting on a
hard surface results in a local pressure of
300–500 mmHg (dependent on weight and sur-
face area). Lying in bed causes a local pressure of
50–94 mmHg on the heels, sacrum and scapula.
A pressure ulcer is a product of both the intensity
and duration of such pressure. There is an inverse
correlation between the duration of sitting and
the intensity of pressure, that is, a pressure ulcer
may develop in less sitting time with strong in-
tensity or in response to a longer duration of sit-
ª 2010 Adis Data Information BV. All rights reserved.
Jaul
ting with low intensity.[64] Therefore, reducing
the intensity of the pressure through use of a
pressure-relieving surface is as important as
frequently repositioning the patient in order to
reduce the duration of pressure on any particular
area of the skin. Physiological changes in the
aging skin include progressive atrophy of the
vasculature and deterioration of the supporting
dermis, such that collagen and elastin become
sparse; all of these changes increase the suscept-
ibility to pressure-induced damage.[16]
Shearing (tangential) pressure occurs when
bone and the subcutaneous layer move against
the skin block in opposite directions to each
other. The capacity to maintain a stable position
while sitting or lying is impaired with age. Elderly
persons tend to slide down while sitting on a chair
or even from a lying position when the head of
the bed is raised more than 30. As a result, the
dermal vessels become twisted, impairing blood
perfusion and favouring the development of
ischaemia. Aging skin is affected by shearing
forces because of a reduction in elasticity which
increases local torsion.[65]
Friction is caused by two forces moving in
opposite directions, in this case the surface of an
external object against the skin. Frequently,
agitated elderly persons rub their heels or elbows
and cause the formation of intra-epidermal blis-
ters, thereby damaging the skin and accelerating
the formation of pressure ulcers. This effect of
friction on developing pressure ulcers is increased
5-fold with accompanying moisture excess.
Moisture causes maceration of the skin, which
facilitates injury to the skin even with light pres-
sure. Moisture may be due not only to urinary or
faecal secretions but also to any other body
fluids, such as perspiration caused by fever or a
hot environment, drainage of a fistula or ex-
cessive secretion from a wound, or wetness after
bathing.[66] There is a synergetic interaction be-
tween moisture and axial pressure.
3.2 Intrinsic (Internal) Factors
The intrinsic (internal) factors focus on the
patient’s pathology, including the various facets of
multiple diseases that contribute to the development
Drugs Aging 2010; 27 (4)
Pressure Ulcers in the Elderly
of pressure ulcers. The mechanism through which
these intrinsic factors work can be explained on
the basis of vascular, degenerative, inflammatory
or metabolic changes.
Some of the principal factors promoting pres-
sure ulcers include impairment of the level of
consciousness, limitation of mobility, diminution
of the sensory system, occlusion of the arterial
vessels and blockage of the venous/lymphatic
vessels. Other factors are incontinence and
wetness formation, agitation and involuntary
movement, and increased spasticity. Oedema
formation, maceration of the skin, dehydration,
immunosuppression, reduced oxygenation and
lack of adequate red and white blood cell com-
ponents are also factors. Medications for other
diseases may produce adverse effects on the skin,
including lowered perfusion due to antihyper-
tensive drugs, a cholinergic effect and increased
spasticity. Finally, other pathological conditions
of the skin that predispose to bedsores, such as
dry skin (xerosis) and skin trauma, should also be
noted.[37,67]
4. Management
Management of pressure ulcers in the elderly is
not limited to local wound treatment alone;
rather, the full pathology of the patient should be
taken into account.
The responsibility for treating pressure ulcers
should be shared by a multidisciplinary team.
The focus of treatment is prevention and re-
medial actions. Medical management includes
stabilizing and curing all reversible medical con-
ditions, treating all irreversible conditions, and
preventing and minimizing complications of the
patient’s dysfunctional status. Other facets of treat-
ment involve the provision of food and fluids,
local wound treatment and family support.
4.1 Stabilization and Cure of Reversible
Medical Conditions and Treatment of
Irreversible Conditions
Where possible, the physician should stabilize
or cure all reversible medical conditions. Treat-
ment of irreversible conditions focuses on stabi-
ª 2010 Adis Data Information BV. All rights reserved.
319
lizing medical effects that are damaging to the
skin. For instance, congestive heart failure with
associated leg oedema may be reversed by giving
intensive diuretic treatment. Hypothyroidism
with associated oedema may be corrected with L-
thyroxine (levothyroxine sodium). Occlusion of
blood vessels is treated by angioplasty and inser-
tion of a stent or by performing a bypass grafting
procedure. If these procedures cannot be im-
plemented, anticoagulation may be achieved with
warfarin, aspirin (acetylsalicylic acid) or clopi-
drogel. Antibacterial drugs are the preferred
treatment for systemic infections. Treatment for
contracture and spasticity in multiple sclerosis,
Alzheimer’s disease and other degenerative dis-
eases involves the use of antispastic medications
such as baclofen, botulinum toxin or physiother-
apy. Levodopa/carbidopa is given to release
rigidity in Parkinson’s disease. Parkinsonism
caused by anticholinergic adverse effects of anti-
psychotic drugs should be stopped by withdrawal
of these drugs. Severe and painful arthritis caus-
ing immobility should be treated by anti-
inflammatory or analgesic drugs.
It is important to review the patient’s entire
medication list, particularly noting medications
with adverse effects such as dryness of the skin,
swallowing difficulties, sleepiness, lowered blood
pressure, bladder dysfunction or constipation.
4.2 Preventing and Minimizing Complications
of the Dysfunctional Status
Immobility is a major risk factor associated
with pressure ulcers and is the focus of pre-
ventative and remedial treatment.
The inability to change position without help
creates a wide range of complications such as
deep venous thrombosis, pulmonary embolism,
osteoporosis, muscular atrophy, constipation,
faecal impaction and pressure ulcers. All of these
phenomena should be prevented. If the cause of
the immobility is reversible or temporary, it is
imperative to start and develop treatment ra-
pidly. For instance, an elderly person affected by
pneumonia should not rest in bed, but be en-
couraged to sit or even walk. Elderly patients
recovering from surgery for hip fracture can be
Drugs Aging 2010; 27 (4)
320
rapidly mobilized. It is important to remember
that a pressure ulcer may appear within hours but
take years to heal. In the initial stages of im-
mobility, use of pressure relief devices such as
mattresses and overlays, cushions, and ankle or
heel protectors should be encouraged. Usage can
be dynamic or static, depending on the potential
for developing pressure ulcers or on the current
stage of the ulcers.
Repositioning is a key factor in the prevention
and treatment of pressure ulcers. It is re-
commended that recumbent patients should be
repositioned every 2 hours and seated patients
every 15–30 minutes. A stable sitting position
should be maintained and slipping prevented by
elevating the posterior seat wedge. For recum-
bent patients, the head of the bed should be kept
at less than 30. Appropriate lifting devices
should be used rather than manual transfer. Ul-
cers caused by spasticity can be prevented by
putting a cushion between direct contact points
of bony prominences such as knees and ankles.
The rehabilitation team (occupational and phy-
sical therapists) should exercise the patient’s
joints through a range of passive motions, thus
preventing the formation of contractures. They
should also instruct orderlies and caregivers on
how to position the patient in bed or in a wheel-
chair through the proper use of pillows and
cushions. Orderlies are often the first members of
the clinical staff to discover a new wound because
they bathe, dress and reposition patients fre-
quently during each shift.
The moisture from urinary incontinence can
be reduced by regularly taking the patient to the
bathroom, changing diapers frequently and ap-
plying cream to the skin. Inserting an external
urinary catheter for the night and changing the
administration time for diuretic medication for
congestive heart failure from day to night is
helpful for the patient and often allows for a
restful sleep. Administering a-adrenoceptor an-
tagonist drugs to ease hypertrophy of the pros-
tate and utilizing anticholinergic drugs to prevent
bladder contraction helps prevent urinary incon-
tinence. In other cases of urinary retention, insert-
ing an indwelling urine catheter is indicated, but
this strategy is debatable as a method for redu-
ª 2010 Adis Data Information BV. All rights reserved.
Jaul
cing wetness as a part of the treatment of pressure
ulcers because of high associated infection rates.
4.3 Provision of Food and Fluids
Despite a strong association between poor
nutritional status and development of pressure
ulcers, a causal relationship has not been estab-
lished.[18] Several studies[38,68-70] have indicated
that impairment of nutritional intake, diminution
in dietary protein intake, reduction in the ability
to feed oneself and recent weight loss are risk
factors for development of pressure ulcers. Early
detection of these nutritional and dietary factors
by the treating physician may prevent dehydra-
tion and malnutrition.
Early nutritional supplementation with addi-
tional calories and protein, either orally or through
use of tube (enteral) feeding (via a nasogastric tube
or a percutaneous endoscopic gastrostomy), may
reduce the risk of developing pressure ulcers.[71,72]
With the use of a feeding gastrostomy it is possible
to feed patients orally with food of adequate tex-
ture to preserve their sense of taste, thereby pro-
viding a source of pleasure while relieving the
burden on the part of the family to feed the patient
orally. However, it is generally agreed that it is not
possible to draw any firm conclusions regarding
the effect of enteral nutrition on the prevention and
treatment of pressure ulcers.[73]
Many elderly patients with pressure ulcers also
suffer from severe dementia and the subject of
tube feeding in this context is a topic of ongoing
clinical and ethical debate.[74] There are those
who maintain that nutritional support via tube
feeding fails to improve patients’ nutritional sta-
tus or even alleviate pressure ulcers.[75] It must
also be taken into account that tube feeding car-
ries the risk of early and late complications such
as aspiration pneumonia and self-extubation.[76]
In this author’s experience, tube feeding extends
patient median survival time significantly,[77,78]
although there was no support for this view in a
systematic review.[79]
Families should be encouraged to discuss the
advantages of tube feeding with the multidisci-
plinary team and agreement to use a gastrostomy
should be based on informed consent. Inserting a
Drugs Aging 2010; 27 (4)
Pressure Ulcers in the Elderly
gastrostomy implies a prior assessment of the
patient’s competence to give consent or alter-
natively requires the appointment of a proxy or
guardian to give assent.
After inserting a gastrostomy tube, the diet-
itian should be consulted regarding the energy
and protein intake required in relation to the
severity of pressure ulcers. Caution is advised in
order to prevent the refeeding syndrome in cases
where the patient has not eaten for a few days.
Therefore, moderation should be exercized with
respect to the initial feeding rate and intake
should be increased gradually.[80]
The recommendations for required feeding set
out by the European Pressure Ulcers Advisory
Panel (EPUAP 2003) are for an energy intake
of 30–35 calories/kg of bodyweight/day, 1–1.5 g
of protein/kg of bodyweight/day and 30 mL of
liquids/kg of bodyweight/day.[81]
4.4 Local Wound Treatment
Local wound treatment has advanced rapidly
in recent years. In particular, significant advances
have been made in wound dressing. The tradi-
tional passive dressings designed to protect the
wound are being replaced by dressings that can
absorb secretions, maintain moisture and en-
courage granulation and re-epithelialization.
Some modern dressings utilize silver ions for anti-
bacterial action, while others contain analgesics
or activated charcoal for its odour-neutralizing
properties. Such dressings simplify the local
treatment of wounds while maintaining a rea-
sonable quality of life for the patient. Certain
dressings may be left in place for a number of
days (as long as there is neither excessive secre-
tion nor local discomfort), thus obviating the
need for frequent visits to the nurse or doctor’s
office. Thus, the patient enjoys the relative free-
dom to maintain a regular lifestyle.[82]
Strategies for local wound treatment in the
elderly are discussed in the following sections.
4.4.1 Debridement and Cleaning
Debridement is the cornerstone for treating
contaminated pressure ulcers (and every ulcer
starts out as contaminated). Debridement is per-
ª 2010 Adis Data Information BV. All rights reserved.
321
formed to remove necrotic tissue, slough and
other nonviable components of the ulcer, to
promote healing[62] and to facilitate staging.
There are several methods of debridement:
surgical (sharp), enzymatic, chemical, autolytic
(permitting the body to perform self-debridement
beneath an occlusive dressing), biological (mag-
got) and mechanical (dry on wet, drip or friction).
These methods may be used in combinations
or sequentially. A common practice for exten-
sive grade 3 and 4 pressure ulcers is to use an
initial sharp debridement in combination with a
mechanical procedure, followed by autolytic
methods.[83]
There is little trial evidence and no firm re-
commendations to support the use of any partic-
ular wound cleansing solution or technique for
pressure ulcers in clinical practice.[84] Further-
more, some controversial preparations are still in
use for local treatment of pressure ulcers,
including antiseptic preparations such as povi-
done-iodine, sodium hypochlorite and hydrogen
peroxide solutions. Some of these antiseptic
preparations damage healing tissue (granulation)
and poison fibroblasts. No improvement in
healing has been found with the use of topical
antibacterial creams over placebo.[85]
4.4.2 Dressings
Once a wound is clean, it is essential to pre-
serve local humidity in order to prevent dressing-
induced desiccation. A variety of dressings is
available: low-adherent dressings, transparent
(film) dressings, hydrocolloid dressings, hydrogel
dressings, foam, alginate and antimicrobial
dressings.[86]
The choice of optimal dressing depends on the
state of the wound, i.e. its stage, the amount of
secretion, its odour and its site. For example, a
stage 3 or 4 ulcer with a large volume of secretion
requires a primary absorbent dressing, such as
alginate, and a secondary dressing, such as
hydrocolloid or foam. A dry wound may require
a primary moisture-preserving primary dressing
such as hydrogel, and a secondary dressing such
as film for stage 2 ulcers and hydrocolloid or
foam for stage 3 or 4 ulcers. A malodorous
wound requires application of activated charcoal
Drugs Aging 2010; 27 (4)
322
for its odour-neutralizing properties.[87] Nurses
serve as the first line in detecting changes in the
patient’s wound status, and the nurses who carry
out the local treatment of the wounds often de-
termine which type of dressing should be applied.
In the treatment of chronic pressure ulcers,
alternative procedures include the use of a local
agent (see section 4.4.4), surgical intervention
and/or complementary treatment (see section
4.4.6). These methods are rarely used in the
elderly because intrinsic (see section 3.2) and
extrinsic factors (see section 3.1) have not been
resolved.
4.4.3 Pressure Relief Devices
Pressure relief devices may be either static or
dynamic. Static support surfaces such as mat-
tresses or overlays are filled with air, water, gel or
foam, or various combinations of these. Dynamic
support surfaces include alternating-pressure
mattresses, low-air-loss beds and air-fluidized
mattresses. When a specialized foam overlay was
compared with a standard operating table mat-
tress, the former was found to significantly de-
crease the incidence of postoperative pressure
ulcers.[88] Specialized foam and sheepskin over-
lays were also consistently superior to standard
hospital mattresses in reducing the incidence of
pressure ulcers.[89,90] When the difference in
pressure ulcer incidence between dynamic and
static support surfaces was evaluated, no clear
differences were seen[91] but both were superior to
the standard surface.[92] No difference was found
in the incidence of pressure ulcers when dynamic
surface overlays were used compared with dy-
namic surface mattresses.[67]
4.4.4 Local Agents
Local agents include an extensive spectrum of
dissimilar products such as solutions, creams,
blood products and skin substitutes. Choices of
treatment are broad, diverse, and usually depend
on practice, personal preference and local medi-
cal customs. The options vary from traditional
ointments, such as sugar, urea and balsam of
Peru, to treatments developed in recent years,
such as genetic engineering and advanced bio-
technology.[93,94] These agents may have minimal
ª 2010 Adis Data Information BV. All rights reserved.
Jaul
advantages when used to treat pressure ulcers but
their usage may provide benefit to some in-
dividuals. Systematic reviews of these treatment
choices have rarely been performed and usage is
left to the choice of the practitioner.
4.4.5 Surgical Intervention
Surgery for pressure ulcers is rarely required in
the elderly. Extensive debridement or excision of
a bony prominence is rare and not advisable for
patients in a poor medical condition. Closure of a
clean wound with a fasciocutaneous or myo-
cutaneous flap is rarely performed as the principal
factor causing the pressure sore, i.e. immobility,
is still present.
4.4.6 Complementary Treatments
Complementary treatments comprise a group
of interventions, both mechanical and physical,
such as gas (hyperbaric oxygen or ozone), light,
sound and electrical stimulation, magnetic fields,
water immersion and negative pressure wound
therapy procedures. All of these modalities have
undergone systematic review and none has been
shown to be of benefit in the treatment of pres-
sure ulcers.[95-100]
4.5 Family Support
The social worker and the doctor should work
together to help patients and their families make
informed decisions based on realistic expecta-
tions. The social worker can assist in obtaining
medical devices and also in identifying and using
community resources. Problems associated with
amputation, insertion of a gastrostomy and pla-
cing the patient in an institution require health-
care professional support as well as an awareness
of cultural beliefs and preferences. The major
decisions should ultimately be made by the pa-
tient and his or her family. It is important to
avoid threatening that the patient will die if these
procedures are not carried out. Palliative treat-
ment, such as symptom control in relation to
pain, constipation, secretions, odour and infec-
tion of the wound, should be provided in terminal
cases. The primary aim underlying patient and
family support is to optimize the patient’s quality
of life.
Drugs Aging 2010; 27 (4)
Pressure Ulcers in the Elderly
5. Conclusions
The primary principle underlying manage-
ment of pressure ulcers is to prevent their occur-
rence taking into consideration the physical and
pathological condition of the patient. The multi-
disciplinary management team must take a broad
approach, not only with respect to the wounds,
but also to the needs of the patient and family.
In some temporary circumstances, such as
postoperatively or after an acute illness, it will be
possible to mobilize the patient rapidly and in-
itiate use of early pressure-relieving devices and
frequent repositioning strategies. Nevertheless,
should a pressure ulcer develop, the goal of the
treating physician should be to heal the ulcer by
addressing and stabilizing underlying illnesses,
augmenting caloric and protein intake, and in-
stituting strategies for pressure relief and fre-
quent repositioning. In cases where the pressure
ulcer becomes chronic, the physician’s goal
changes from that of healing to one of optimizing
the patient’s quality of life, controlling the
symptoms (pain, discomfort, foul odour, infec-
tion), supporting the family, and dealing with
ethical and end-of-life issues.
Acknowledgements
No sources of funding were used to assist in the prepara-
tion of this review. The author has no conflicts of interest that
are directly relevant to the content of this review. The author
would like to thank Dr Sheva Mann, Professor Arnold Rosin
and Iris Arad for their help in editing the article.
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Correspondence: Efraim Jaul, Director, Skilled Geriatric
Nursing Department, Herzog Hospital, PO Box 3900,
Jerusalem 91035, Israel.
E-mail: jaul@zahav.net.il
Drugs Aging 2010; 27 (4)