What is the best management approach for a black, non-tender, closed pressure ulcer on the heel of a patient with advanced dementia in a Long-Term Care (LTC) setting?

From the Guidelines

For a black, non-tender pressure ulcer on the heel of a patient with advanced dementia in long-term care, the primary recommendation is to consult with a wound care specialist immediately and use advanced static mattresses or advanced static overlays to prevent further pressure ulcers, as recommended by the American College of Physicians 1. The patient's advanced dementia and non-tender pressure ulcer require careful consideration to prevent further complications.

• The use of advanced static mattresses or overlays is supported by moderate-quality evidence, which shows a lower risk for pressure ulcers compared with standard hospital mattresses 1.
• It is essential to keep the area clean and dry, completely offload pressure from the heel using a pillow or specialized heel suspension boot, and monitor for signs of infection such as increased warmth, swelling, odor, or drainage.
• Nutritional support is crucial, so ensure adequate protein intake (1.2-1.5 g/kg/day) and consider supplements like zinc and vitamin C if deficient, as supported by the American College of Physicians guidelines 1.
• For pain management, even though the patient reports no tenderness, consider scheduled acetaminophen as patients with dementia may not reliably report pain.
• Document the size, appearance, and any changes in the wound daily to ensure proper monitoring and adjustment of the treatment plan. The conservative approach is appropriate because premature debridement could expose deeper tissues to infection, and the patient's advanced dementia may complicate wound care and healing.
• The American College of Physicians recommends against using alternating-air mattresses or alternating-air overlays in patients who are at an increased risk of developing pressure ulcers, due to the lack of clear benefit and higher costs 1.

From the Research

Management Approach for Black, Non-Tender, Closed Pressure Ulcer

• The management of a black, non-tender, closed pressure ulcer on the heel of a patient with advanced dementia in a Long-Term Care (LTC) setting involves a comprehensive approach, considering the patient's overall health and well-being 2, 3.
• The goals of treatment include avoiding preventable contributing circumstances, optimizing regional blood flow, managing underlying illnesses, and providing adequate caloric and protein intake 3.
• Debridement may be indicated if necrotic tissue is present, and wound cleansing with normal saline and appropriate dressings is a mainstay of treatment for clean ulcers and after debridement 2.
• Topical antibiotics should be considered if there is no improvement in healing after 14 days, and systemic antibiotics are used in patients with advancing cellulitis, osteomyelitis, or systemic infection 2.

Considerations for Patients with Advanced Dementia

• Patients with advanced dementia are at risk for chronic wounds, including pressure ulcers, and are rarely included in research 4.
• The prevalence of pressure ulcers in patients with dementia is high, and the management of these ulcers requires a multidisciplinary approach, considering the patient's underlying pathologies, co-morbidities, functional state, and degree of social and emotional support 3.
• The use of alternating pressure air mattresses may be recommended instead of two-hourly repositioning, which may breach the rights of residents and fail to prevent pressure ulcers in at-risk residents 5.

Patient Involvement and Adherence to Prevention Strategies

• Patient involvement in pressure ulcer prevention and adherence to prevention strategies is crucial, and individual and daily lifestyle considerations, as well as involvement in decision-making around pressure ulcer care, are important aspects from the patient perspective 6.
• Further research is necessary to explore which factors affect patient adherence and to improve clinical practice and support patient involvement in preventative strategies 6.