Lesions on the skin that are caused by pressure resulting in tissue damage are often found on the lower limbs, but can occur almost anywhere

Pressure ulcers — better known as bedsores — are lesions on the skin that are caused by unrelieved pressure resulting in tissue damage. they usually develop over bony areas of the body, often in the lower limbs (ankles and hips are common), but they can occur almost anywhere (for example, in the nostrils of patients with feeding tubes, in the corners of the mouth in patients with endotracheal tubes, and between fingers in patients with rheumatoid arthritis).

Pressure ulcers are quite common in hospitals and other institutional settings. in acute care hospitals they occur in about 3-15 percent of patients; (1) (2) (3) (4) they occur in about a third of elderly patients who have had hip fractures; (5) and the number rises to as much as 50 percent in critical care patients. (6) ten to 35 percent of patients admitted to nursing homes have pressure ulcers, though this rate decreases somewhat for patients who have been there longer. (7) (8) (9) (10) because there are other reasons for skin breakdown, it is important to be examined and diagnosed by a doctor so that the appropriate treatment can be determined. in this article, we’ll discuss the symptoms and diagnosis of ulcers, as well as their treatment and tips for prevention.

TYPES OF ULCERS

There are several types of skin ulceration. Pressure ulcers or bedsores occur when the skin is subjected to constant pressure, which is why they happen so frequently in hospitals and in older patients. they generally start as a blister, and then become an open sore, finally ending in a “crater.” in addition to pressure ulcers, areas of skin breakdown may be due to other types of ulcers, having to do with insufficient blood flow or to diabetic neuropathy.

Insufficient blood flow through the veins usually occurs in the lower legs, and can result in venous insufficiency ulcers, which are often chronic and difficult to heal. they can cause pain in the foot and usually appear purplish in color. they are never found above the level of the knee or in the forefoot, and may occur singly or in multiples.

A related condition, caused by insufficient blood flow through the arteries, is known as arterial insufficiency ulcers, which are painful lesions that usually occur over the ankle or other areas of the foot. although they may be seen near bony prominences (i.e., joints), they are distinguished from pressure ulcers by their “punched-out” or star-like appearance. The wound may be pale and dry, surrounded by red and taut skin, and can include an area of dead skin.

Diabetic ulcers occur on the foot, usually over the joints or on the top of the toes. these ulcers often occur on the ball of the foot in diabetic patients, due to neuropathy or repetitive injury. Diabetic foot ulcers are often surrounded by a significant thickening of the skin, and are usually insensitive to touch.

There are other, less common causes of ulcers in the legs and feet, which include connective tissue diseases (e.g., rheumatoid arthritis), sickle cell disease, and certain forms of cancer. One’s doctor should take special precaution to rule out these more serious conditions before arriving at a diagnosis of an ulcer.

CAUSES AND RISK FACTORS OF PRESSURE ULCERS

Internal and External Risk Factors

There are both external and internal risk factors for ulcers. Pressure, friction, shearing (two layers of skin sliding on each other in opposite directions), and moisture (which can cause softening of skin) are considered external (or extrinsic) risk factors. Internal or intrinsic factors have to do with the patient’s state of health: these including underlying medical conditions, immobility, inactivity, fecal and urinary incontinence, malnutrition, decreased consciousness, steroid use, and smoking, which can all influence one’s likelihood of developing an ulcer.

Medical conditions linked to intrinsic risk factors are far-ranging and include anemia, infection, peripheral vascular disease, edema, diabetes, stroke, dementia, delirium, alcoholism, fractures, and malignancies. Simple, age-related factors such as reduced fat and muscle mass with which to dissipate pressure also increase risk. lower levels of Vitamin C as one ages may also increase the risk of pressure ulcers by causing blood vessels and connective tissue to become fragile and reducing the number of blood vessels serving the tissue of the skin, and other factors.

The Underlying cause of Ulcers: Tissue Ischemia

A main cause of pressure ulcers is tissue ischemia, which occurs when there is a loss of adequate blood supply to the tissue (skin) in question, caused by excessive pressure on the skin. Pressure to the skin lasting longer than two hours produces irreversible changes in skin tissue. in patients who tend to develop pressure ulcers post-operatively, there is impairment in skin blood flow over bony areas of the skin during surgery. (11)

When a person sits, their sitting bones bear the greatest pressure, often pressure than your capillaries can technically take. (12) Pressure ulcers can actually occur from the “inside-out” given that the muscle is more sensitive to pressure than is the skin. (13) because the outer layer of the skin shows signs of tissue death relatively late in the development of an ulcer, (14) once the skin starts to show indications of the presence of an ulcer, the ulcer may be even more progressed than meets the eye. Factors such as hypotension (low blood pressure), dehydration, heart failure, or medications may also contribute to pressure ulcer development. (6) (15) (16) (17) (18) (19)

(1) Pressure ulcers prevalence, cost and risk assessment: consensus development conference statement–The National Pressure Ulcer Advisory Panel. Decubitus 1989; 2:24-8.

(2) Pressure ulcers in America: prevalence, incidence, and implications for the future. An executive summary of the National Pressure Ulcer Advisory Panel monograph. Adv Skin Wound Care 2001; 14:208-15.

(3) Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Multi-site study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses, and prescription of preventive interventions. J am Geriatr Soc 1996; 44:22-30.

(4) Baumgarten M, Margolis DJ, Localio AR, Kagan SH, Lowe RA, Kinosian B, et al. Pressure ulcers among elderly patients early in the hospital stay. J Gerontol a Biol Sci Med Sci 2006; 61:749-54.

(5) Baumgarten M, Margolis DJ, Orwig DL, Shardell MD, Hawkes WG, Langenberg P, et al. Pressure ulcers in elderly patients with hip fracture across the continuum of care. J am Geriatr Soc 2009; 57:863-70.

(6) Inman KJ, Sibbald WJ, Rutledge FS, Clark BJ. Clinical utility and cost-effectiveness of an air suspension bed in the prevention of pressure ulcers. JAMA 1993; 269:1139-43.

(7) Brandeis GH, Morris JN, Nash DJ, Lipsitz LA. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990; 264:2905-9.

(8) Spector WD, Kapp MC, Tucker RJ, Sternberg J. Factors associated with presence of decubitus ulcers at admission to nursing homes. Gerontologist 1988; 28:830-4.

(9) Shepard MA, Parker D, DeClercque N. The under-reporting of pressure sores in patients transferred between hospital and nursing home. J am Geriatr Soc 1987; 35:159-60.

(10) Reed JW. Pressure ulcers in the elderly: prevention and treatment utilizing the team approach. Md State Med J 1981; 30:45-50.

(11) Sanada H, Nagakawa T, Yamamoto M, Higashidani K, Tsuru H, Sugama J. The role of skin blood flow in pressure ulcer development during surgery. Adv Wound Care 1997; 10:29-34.

(12) Lindan O, Greenway RM, Piazza JM. Pressure distribution on the surface of the human body. I. Evaluation in lying and sitting positions using a “bed of springs and nails”. Arch Phys Med Rehabil 1965; 46:378-85.

(13) Le KM, Madsen BL, Barth PW, Ksander GA, Angell JB, Vistnes LM. An in-depth look at pressure sores using monolithic silicon pressure sensors. Plast Reconstr Surg 1984; 74:745-56.

(14) Witkowski JA, Parish LC. Histopathology of the decubitus ulcer. J am Acad Dermatol 1982; 6:1014-21.

(15) Bergstrom N, Braden B. a prospective study of pressure sore risk among institutionalized elderly. J am Geriatr Soc 1992; 40:747-58.

(16) Schubert V. Hypotension as a risk factor for the development of pressure sores in elderly subjects. Age Ageing 1991; 20:255-61.

(17) Mawson AR, Biundo JJ Jr, Neville P, Linares HA, Winchester Y, Lopez a. Risk factors for early occurring pressure ulcers following spinal cord injury. am J Phys Med Rehabil 1988; 67:123-7.

(18) Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995; 273:865-70.

(19) Horn SD, Bender SA, Ferguson ML, Smout RJ, Bergstrom N, Taler G, et al. The National Pressure Ulcer Long-Term Care Study: pressure ulcer development in long-term care residents. J am Geriatr Soc 2004; 52:359-67.

The number of Minnesotans with Alzheimer’s disease and other forms of dementia will swell from 88,000 now to 198,000 in the next 30 years, with the prospect that state coffers, families and employers could be overwhelmed by the stress and costs of care, according to a report that will be delivered to the Legislature on Thursday.

Without action, the report concludes, “the burden will be heaviest on public funding as the number of individuals with Alzheimer’s increase and their family caregivers are stretched beyond their capacity and exhaust their resources.”

Fear of the disease and ignorance about treating symptoms have kept many Minnesotans from getting help until caregivers are exhausted and in chaos, advocates say.

The result, they say, is a heavy drain on personal and state finances as patients are placed sooner than necessary in nursing homes and families are battered by the unrelenting stress of caregiving.

“Minnesota is in crisis now — with huge costs and stresses to families, employers and government — and it will get worse as the population ages,” said Mary Birchard, executive director of the state Alzheimer’s Association, which helped lead the group that developed the report.

Cost savings could be significant, the report says — an attractive prospect, even if not implemented this session, as the state wrestles with a projected $6.2 billion deficit.

With average annual medical costs for an Alzheimer’s patient running about $33,000 — triple that of similar people without dementia — cutting expenses even by $5,000 per patient could save $44 million a year.

Communities and families must act to ensure better care and better use of public and private resources, the report says.

In a small way, that’s exactly what happened early this week in new Prague with the family of 77-year-old Rollie Tietz .

To cope with the retired businessman’s periodic wandering — a frightening behavior that affects 60 percent of Alzheimer’s patients— Tietz’s family enlisted the help of the police department and two sheriffs’ offices to test a device to track him the next time he takes a walk into the snowy night wearing slippers.

For months, Rod Tietz has been worried about his dad, who lives 3 miles outside new Prague. he checked out several devices that could track his dad should he go missing. he chose one sold by EmFinders  of Frisco , Texas, using cell phone technology.

“you read about these cases where somebody with Alzheimer’s is found dead and you just don’t want that to be your dad,” Rod Tietz said.

On Monday, he gathered a crowd at the new Prague police department. With his dad at home wearing a device like a wrist watch, Tietz asked his mom to call 911 to report the test, then call the company’s 800 number.

Within 10 minutes, the device sent a 911 call that gave authorities his dad’s location on a map, with latitude and longitude coordinates — within 100 yards of the house. a second test found a patrolman wearing a similar device.

“this is pretty good,” said Police Chief Mark Vosjepka . “We’ve got a better chance of finding somebody alive, and it cuts way down on our manpower needs.”

Rollie’s wife, Joanie Tietz, 72, also expressed relief.

“I worked 27 years as an EMT with the ambulance crew and I’ve seen a lot of bad stuff,’’ she said. “but this Alzheimer’s, it can just grind you down. I was starting to think, well, how much longer can we go on?”

First, early detection  

With 23 recommendations for the Legislature and others for state agencies and the University of Minnesota, the report is among the most comprehensive undertaken in 14 states that have conducted similar analyses, organizers say.

The report’s first proposal: Train and encourage doctors to detect Alzheimer’s disease early — something often resisted both by doctors and families — which could save the state an average of $10,000 per patient a year.

“There is no cure, but with early detection, treatment can slow the decline by 12 to 18 months for more than half of patients,” said Michelle Barclay , a vice president at the state Alzheimer’s Association, which helped staff the 20-member group appointed by the Legislature in 2009. The group met for 15 months and involved about 100 others to develop the report.

Initial legislation will be sponsored by Rep. Steve Gottwalt, R-St. Cloud, who led the effort to set up the work group and chairs the House Health and Human Services Reform Committee. his bill will likely seek a better accounting of Minnesotans with dementia and refine care strategies.

Other recommendations include: Require cognitive screening for all Minnesotans 65 and older in state-paid health programs; create a “dementia clearinghouse website” with information for families and professionals; adopt a state “gold standard” for dementia care, and reinstate a geriatrics medical education program at the University of Minnesota.

Additional recommendations for communities and families will be developed by a new work group that starts in several months, officials said.

“In some ways, we don’t have a choice,” said Birchard. “We act soon … or the situation will be unmanageable.”

The 71-page document, “Preparing Minnesota for Alzheimer’s: The Budgetary, Social and Personal Impacts,” is available at alz.org/mnnd . 

Warren Wolfe • 612-673-7253