Pressure ulcers (bedsores)
Pressure ulcers - also called pressure sores or bedsores - can develop if someone spends too long sitting or lying in one position. They are a particular risk for people with dementia. It is important for anyone caring for a person with dementia to know about pressure ulcers. They can be easy to prevent early on but, if early signs of damage are not noticed, they can get worse and become very painful or infected. This factsheet, for carers at home, explains what pressure ulcers are and how to prevent them.
What is a pressure ulcer?
A pressure ulcer is an area of skin - and sometimes also the tissue underneath - that has become damaged because of pressure. An ulcer may develop over bony areas that are close to the skin. The ulcer forms because the blood supply to the skin is reduced and the skin becomes starved of oxygen and nutrients.
Sitting or lying in the same position for too long is a common cause of pressure ulcers. If skin becomes thin, dry or weak due to ageing or disease, pressure ulcers also become more likely.
Older people in general are at higher risk of pressure ulcers, particularly if they have difficulty moving. Dementia makes this risk even higher, especially as it progresses. This is because of problems that a person with dementia may have with:
- movement and walking - people with dementia may have difficulty changing position without help. This can be when they are moving between their bed and a chair, or repositioning themselves while sitting or lying down. People who are caring for them may also sometimes discourage or limit movement because they are afraid the person with dementia will fall.
- frailty - this causes the loss of protective fat and muscle mass, and also means the skin can become thinner.
- poor diet and dehydration - not eating and drinking well can weaken the skin and make it less able to heal itself.
- incontinence - moisture from leaks can damage the skin.
- poor blood supply - conditions such as diabetes or vascular disease (eg in vascular dementia) increase the risk of ulcers.
- agitation or restlessness - rubbing of clothes, often over the heels or elbows, damages the skin and makes ulcers more likely.
- medication - some medicines can cause the person to be more sleepy or the skin to dry out.
- communication - the person may be less able to tell someone that they are in pain or want to move.
Spotting the signs
If a person has red patches anywhere on their skin (especially over raised bony areas), and these stay red when pressed lightly with a finger, this may well be an early sign of pressure ulcers. Do not ignore these signs.
The area may also be painful, hard or hot to the touch.
Pressure ulcers may be more difficult to detect in people with darker skin. They may show up as patches, with a blue or purple tint, that do not go away.
If you help a person with dementia to wash or dress, always take a few moments to check their skin, especially around bony areas. Pressure ulcers are most likely to appear on the heels, ankles, knees, buttocks, hips, spine, elbows, shoulder blades and the back of the head.
If you think you have found a pressure ulcer, contact the GP as soon as possible and seek advice. It is important to act quickly, but not to feel that you are to blame.
If you have noticed a pressure ulcer at a very early stage (called a category 1 ulcer) the GP will usually arrange for the district or community nurse to assess the person and offer advice. The most important part of any treatment is to remove the cause of the pressure or friction and help the person to move around where possible.
The nurse can also talk to you about aids to protect the body (such as pressure-relieving pads, special cushions, overlays or mattresses) and how to get hold of them. These aids can help prevent pressure ulcers developing or getting worse. There should be no charge for their use. Although they are important, they do not replace the need to move and reposition the person. The nurse may also advise on correct sitting or lying positions (eg supporting the feet).
If the skin has broken (called a category 2 pressure ulcer), the district or community nurse will need to investigate further and ensure that the right treatment is given. As part of this assessment the nurse may take a photograph of the area. This makes it easier to compare the ulcer over time and see whether any treatment is working. For category 2 ulcers, treatment will generally include cleaning the wound and applying a dressing. The aim is for the ulcer to heal properly and not become a long-term ('chronic') problem, or one which requires hospital treatment. It is essential that the person avoids lying or sitting on the sore area.
A pressure ulcer of any type can be extremely painful, so regular pain relief is important. Paracetamol is often very effective for this.
Some pressure ulcers, particularly chronic ulcers, become infected and even more painful. At worst, this can make the person seriously ill with blood poisoning or infection of the bone. Treatment for an infected ulcer is likely to include antibiotics or a special dressing.
Tips for carers: preventing pressure ulcers
Lying in bed
When people are in bed, they normally move around - even when they're sleeping. But in the later stages of dementia, people may move a lot less and can also develop physical disabilities, so they may be in the same position for substantial periods. This can lead to pressure ulcers developing.
- Try to make sure the person doesn't stay in one position for more than a couple of hours.
- Encourage them to get up during the day and move around as much as possible, either independently or with some help. Consider using a memory aid - eg a timer alarm - to encourage the person to change position independently.
- Ask the nurse or an occupational therapist to show you how to help the person move or transfer between their bed and a chair safely. There are lifting aids available that may help.
- Talk to the nurse about pressure-relieving pads, overlays or mattresses.
Sitting in a chair or wheelchair
Most people shift around naturally when they are sitting down. But in the later stages of dementia, people are more likely to stay in one position for a long time. This can lead to pressure ulcers developing.
- Encourage the person to change their position in the chair every 15-30 minutes while they're sitting.
- Help them stand up and walk around at least every couple of hours if they are able.
- Ask the community nurse about pressure-relieving seat cushions.
- Ask about being referred to an occupational therapist, especially if the person needs a wheelchair or specialist seating.
Avoiding friction on the person's skin
As people age, their skin becomes more delicate. Even gentle friction on the skin can, over time, increase the risk of pressure ulcers.
- If you help the person to move, be careful not to drag them across the bed or chair.
- Help the person to sit up in the right position while in bed. If they continually have to resist sliding down by trying to push themselves back, this will put pressure or cause friction on the heels and base of the spine.
- Make sure there are no rough seams in their clothes, or anything in their pockets that could rub against the skin.
- Check that bedding is smooth. Wrinkles in the sheets can contribute to pressure ulcers. If the person is in the later stages of dementia, they may not be able to explain easily that they're feeling uncomfortable.
- Consider bed linen and clothing made from natural fibres, such as cotton or linen. These are less likely to cause pressure ulcers than synthetic materials.
- Help the person exercise regularly. Chair-based exercises can help a person to stay flexible and can also relieve pressure. Exercise also improves circulation. For advice on suitable exercise, ask the GP for a referral to a physiotherapist. For more information, see factsheet 529, Exercise and physical activity.
- Try to make sure that the person eats a good balanced diet, with plenty of protein (eg eggs, fish, meat) and fresh fruit and vegetables. They should also drink plenty of fluids. Good nutrition makes the skin healthier and more resistant to ulcers. The GP may offer a referral to a community dietitian. If the person has difficulty swallowing, ask the GP for a referral to a speech and language therapist. For more information see factsheet 511, Eating and drinking.
- If the person has problems with incontinence, make sure they don't stay in wet clothes or a wet bed. If skin is in contact with urine for any length of time, it will be more at risk of ulcers. For more information see factsheet 502, Continence and using the toilet.
- Excessive heat and moisture can contribute to pressure ulcers, so try not to let the person become hot and sweaty.
- Avoid close-fitting clothing or tight bedding, especially over the feet.
- Make sure the person is completely dry after a bath or a wash, particularly in the skin folds. Pat them dry - don't rub. For more information see factsheet 504, Washing and bathing.
- Never rub or massage any places where the skin has turned red, as this could cause further damage.
Skin changes at the end of life
The skin of a person who is near to the end of their life often shows changes that can't be reversed (eg mottling). These changes are a normal part of the body shutting down. For a person who is within days or weeks of dying, skin changes such as pressure ulcers are often unavoidable, even with the best treatment.
As part of good end-of-life care, the person with dementia (if possible) and their family should be prepared for these skin changes. This will be a difficult time and discussions with the healthcare team may shift away from working to heal any ulcers. Instead, care at end of life is focused on making the person as comfortable as possible, including pain relief.
Other useful organisations
A national movement that is working to reduce the number of pressure ulcers in the UK. The Your Turn campaign aims to prevent pressure ulcers through education. It helps people understand who is at risk, and what they can do to avoid getting a pressure ulcer.
Last reviewed May 2013 by Heidi Guy, Tissue Viability Clinical Nurse Specialist, Lister Hospital, Stevenage, Hertfordshire and Jane Buswell, Independent Nurse Consultant and Chair, Older People's Specialist Nurse and Senior Practitioner Group, British Geriatrics Society
Last reviewed: September 2016 by Alzheimer's Society.
Next review due: September 2019.
This factsheet has also been reviewed by people affected by dementia.
A list of sources is available on request.