What is the management of bed sores (pressure ulcers) in elderly patients or those with severe neurological conditions and limited mobility?

Management of Bed Sores (Pressure Ulcers)

Implement systematic repositioning every 2-4 hours around the clock combined with advanced static mattresses, early mobilization, daily skin assessment, and high-protein nutritional supplementation to prevent progression and promote healing. 1

Immediate Pressure Relief and Repositioning Protocol

The cornerstone of bed sore management is eliminating ongoing pressure through systematic repositioning every 2-4 hours, which reduces pressure ulcer incidence from 15.1% to 5.2% (p < 0.0001). 1

• Use the 30-degree tilt position rather than standard 90-degree lateral rotation when repositioning, as this reduces pressure on bony prominences (relative risk 0.62) 1
• Avoid the flat supine position entirely, as this concentrates pressure on vulnerable areas 1
• Elevate the upper body ≥40 degrees in patients who can tolerate this position 1
• Document each position change with time and skin assessment findings to ensure adherence 1
• Begin mobilization as soon as medically stable, starting with passive range-of-motion exercises for at least 20 minutes per zone, even in patients who cannot actively participate 1

Critical caveat: Do not delay repositioning for hemodynamically stable patients—vasopressor use is not a contraindication to position changes. 1

Essential Support Surface Interventions

Use advanced static air mattresses or dynamic mattresses immediately for all patients with existing pressure ulcers. 1, 2

• Advanced static mattresses are superior to standard hospital mattresses and allow repositioning intervals to be extended to 4 hours without increased ulcer incidence 1
• Avoid alternating-air mattresses as they are not superior to advanced static surfaces and are more expensive 1
• Apply pressure-relieving devices including specialized cushions, foam, and pillows to avoid interosseous contact, particularly at the knees 3
• Specialized support surfaces reduce pressure ulcer risk with moderate-quality evidence 1

Daily Comprehensive Skin Assessment

Conduct thorough visual and tactile skin checks of all at-risk areas at least once daily, with particular attention to the sacrum, heels, ischium, and occiput. 1

• Use validated risk assessment tools such as the Braden Scale upon admission and reassess regularly based on clinical condition changes 3
• Monitor for early signs of tissue damage including non-blanchable erythema, warmth, edema, or induration 4
• Recognize that every patient with limited mobility is at risk for developing sacral, ischial, trochanteric, or heel ulcers 4

Important pitfall: The Braden Scale has limited diagnostic accuracy and should not replace clinical judgment—do not delay preventive interventions while waiting for formal risk assessment. 1

Wound Care and Debridement

For existing ulcers, perform early mechanical debridement of all nonviable tissue and establish a moist wound-healing environment. 4, 5

• Use hydrocolloid dressings as primary treatment for Stage I-II pressure ulcers, as they are superior to gauze dressings for reducing wound size 2
• For Stage III-IV ulcers, use hydrocolloid or foam dressings after debridement 2
• Perform sharp debridement of necrotic tissue and callus when not contraindicated 2
• Treat systemic or local infection aggressively 5
• Consider vacuum-assisted closure (VAC) therapy for wound conditioning 5

Do not use dressings with antimicrobial agents solely to accelerate healing (strong recommendation, low-quality evidence). 2

Nutritional Optimization

Provide high-protein nutritional supplementation for all patients with pressure ulcers, as malnutrition significantly impairs wound healing. 3, 1

• High-protein oral nutritional supplements (30 energy percent protein) reduce the risk of developing pressure ulcers (odds ratio 0.75; 95% CI 0.62–0.89) 3
• Aim for formulas with 61 g protein per liter (24 energy percent) rather than 37 g protein per liter (14 energy percent) for better healing outcomes 3
• Protein or amino acid supplementation may improve healing rates (weak recommendation, low-quality evidence) 2
• Avoid vitamin C supplementation alone as it shows no benefit over placebo 2
• Consider tube feeding (PEG preferred over NGT for >4 weeks) if oral intake is inadequate 3

Skin Care and Hygiene

Keep skin clean and dry at all times, addressing incontinence promptly as urinary or fecal incontinence increases skin maceration and ulcer risk. 3

• Apply barrier sprays and lubricants judiciously to protect skin from friction during repositioning 3
• Take care when removing dressings or diathermy plates, as elderly skin is thin and liable to damage by minimal trauma 3
• Frequent turning and close surveillance of the skin help prevent pressure sores 3

Adjunctive Therapies for Non-Healing Ulcers

Consider electrical stimulation and platelet-derived growth factor for severe ulcers that fail to respond to traditional therapies. 2, 4

• Electrical stimulation may accelerate healing but lacks evidence for complete wound closure (moderate-quality evidence) 2
• Biological therapy should be reserved for patients whose wounds fail to respond to more traditional therapies 4

Multicomponent Prevention Program

Establish a comprehensive prevention program with standardized protocols, multidisciplinary team involvement, ongoing staff education, and sustained audit and feedback. 1

• Designate "skin champions" to educate personnel on preventive care 1
• Implement regular audits and feedback on pressure ulcer rates 1
• Simplify and standardize specific interventions for pressure ulcer prevention and documentation 1
• This bundled approach has demonstrated cost savings of approximately $11.5 million annually in hospital systems while significantly reducing pressure ulcer prevalence 1

Special Considerations

Each pressure ulcer costs approximately $30,000 to heal, and bed-bound patients with pressure ulcers are almost twice as likely to die as those without. 3, 4

• Prolonged immobilization complications appear and rapidly escalate after 48-72 hours, including pressure sores that may require skin grafting and become sources of sepsis 3
• Among elderly patients with cervical spine injuries, 26.8% died during treatment, principally from respiratory complications related to immobilization 3
• For patients with increased intracranial pressure, position the head in a centered position and avoid lateral rotation during repositioning 1
• Monitor for repositioning intolerance, though this should not prevent adherence to the protocol 1

If pressure ulcers are treated with a comprehensive regimen upon early recognition, nearly all stage IV ulcers can be avoided, significantly reducing comorbidities, mortalities, and treatment costs. 4