Pressure ulcers (bed sores)
Pressure ulcers - also called pressure sores or bed sores - 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 go unnoticed ulcers can get worse and become very painful or infected. This factsheet explains what pressure ulcers are and looks at ways to prevent them.
What is a pressure ulcer?
A pressure ulcer is an area of skin - and sometimes also the underlying tissue - that has become damaged because of pressure and/or force. 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 it becomes starved of oxygen and nutrients. Sitting or lying in the same position for too long is a common cause.
Older people in general are at higher risk of pressure ulcers, particularly if they have difficulty moving. Dementia increases this risk further, especially as it progresses. Pressure ulcers are linked to dementia because of various associated problems:
- Mobility - People with dementia may have difficulty changing position without help. This can include problems with walking, transferring between bed and chair, or repositioning themselves. Their movement may also be restricted by others for fear of falls.
- Frailty - This causes loss of protective fat and muscle mass, with thinning of the skin.
- Poor diet and dehydration - These reduce the strength and healing capacity of the skin.
- Incontinence - Moisture damages 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, causes friction on the skin.
- Medication - Some of these can cause sedation or drying of the skin.
- Communication - The person may be less able to tell someone that they are in pain.
Any red patches appearing anywhere on the skin (particularly over raised bony areas), and that stay red when light finger pressure is applied, may well be early signs of pressure ulcers. They should not be ignored. 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, which do not go away.
Spotting the signs
If you help a person with dementia to wash or dress, always take a few moments to check their skin, especially around bony areas. Heels, ankles, knees, buttocks, hips, the base and prominences of the spine, elbows, shoulder blades and the back of the head can be especially vulnerable.
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) and contacted the GP, the district or community nurse will come 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 advise on 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. They range from foam mattresses or overlays to special mattresses with air-filled sacs which inflate and deflate in turn. 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, such as 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 most appropriate treatment is given. As part of this assessment the nurse may take a photograph of the area. This makes it easier to 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 in these situations.
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 and/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 often lose their motivation and can also develop physical disabilities, so they may lie still for long periods. This lack of movement 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 such as a timer alarm to encourage independent position changes.)
- Ask the nurse for advice on how to help the person move or transfer between bed and 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 an extended 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 a wheelchair or specialist seating is required.
Avoiding friction on the person's skin
As people age, their skin becomes increasingly delicate. Even quite moderate friction on the skin can, over time, cause 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 in the right position. If they continually have to resist sliding down, 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. Even 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 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 maintain flexibility and relieve pressure. Exercise also improves circulation. Consult a physiotherapist for advice on suitable exercise. The GP can provide a referral. For more information, see factsheet 529, Exercise and physical activity for people with dementia.
- 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. Good nutrition makes the skin healthier and more resistant to ulcers. A referral to a community dietitian may be appropriate. Keep fluid levels up too. If the person has difficulty swallowing, ask the GP for a referral to a speech and language therapist. See factsheet 511, Eating and drinking for more information.
- 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 becomes more susceptible to ulcers. See factsheet 502, Managing toilet problems and incontinence for more information.
- 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.
- Never rub or massage any places where the skin has reddened, as this could cause further damage.
Skin changes at the end of life
The skin of a person who is approaching the end of their life often shows irreversible changes: the skin, like the heart or kidneys, is an organ which begins to fail. 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. Discussions with the healthcare team at this difficult time may shift away from working to heal any ulcers. Instead care may seek to make 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
Next review due: May 2016
Reviewed 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
This factsheet has also been reviewed by people affected by dementia.
A list of sources is available on request.