The Experience of a Geriatric Hospital at Home Service for Acutely Ill Elderly Patients With Pressure Ulcers
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Abstract: Background. Pressure ulcers are an often underestimated problem affecting elderly patients. Methods. An observational study was undertaken to evaluate patients admitted from January 2000 to December 2001 to a geriatric hospital affiliated at home service. Results. Four hundred sixty-six patients (44.4% men and 55.6% women) were enrolled. Seventy-nine (16.9%) patients presented with a pressure ulcer upon admission. These patients were more functionally and cognitively impaired and had the poorest nutritional status. Anorexia and asthenia were significantly higher in patients with pressure ulcers (P < 0.001), and prevalence of constipation and dysphagia was significantly different between the two groups (P < 0.05). Relative risk of new onset of pressure ulcers was significantly linked to age (1.09, CI 95% 1.02–1.15), to the number of functions lost (1.79, CI 95% 1.15–2.78), and to comorbidity (2.79, CI 95% 1.26–6.18). The relative risk of death during hospital admission was significantly linked to age (1.02, CI 95% 1.00–1.05), number of activities of daily living (ADL) functions lost (1.2, CI 95% 1.08–1.33), underweight (1.31, CI 95% 1.06–1.62), and the presence of pressure ulcers (1.59, CI 95% 1.23–2.05). Conclusion. Home treatment of acutely ill elderly patients with pressure ulcers
is feasible and efficacious.
Address correspondence to:
Gianluca Isaia, MD
Department of Medical and Surgical Disciplines, Geriatric Section
University of Torino, San Giovanni Battista Hospital
Phone: 00 3933 4881 5921
Email: gianlucaisaia@yahoo.it
Persons age 65 years and older represent 18% of the Italian population but account for 45.5% of hospital admissions.1 Pressure ulcers are commonly found among older people and are a result of many different causes such as malnutrition, immobilization or poor mobilization, and trauma. Malnutrition is an often underestimated problem that affects elderly patients both at home and in the hospital. Protein energy malnutrition has been reported in up to 15% of community dwelling and in 62% of hospitalized elderly individuals.2 Several factors have been cited as influencing and determining malnutrition in the elderly, the most important of which are functional and cognitive impairment, numerous medication prescriptions, and depression3; these factors all play an important role in limiting appetite and reducing food intake.
Furthermore, malnutrition is an important factor involved in the onset of pressure ulcers. Several clinical trials have shown an increase in pressure ulcers among malnourished subjects or subjects who experience a decrease in protein and energy intake.4,5 It is well known how pressure ulcers negatively influence the health status of elderly people. The European Pressure Ulcer Advisory Panel (EPUAP) defined pressure ulcers as, “an area of localized damage to the skin and underlying tissue caused by pressure, shear, friction, and/or a combination of these things.”6
Pressure ulcers seem to be more frequent in long-term facilities with a prevalence of 27.7%7,8 and an incidence of 23.9%9 among admitted patients. Sari and colleagues10 reported a pressure ulcer incidence of 3.8% for patients age 75 years or younger; however, this number greatly increases for patients older than 75 years. Moreover, pressure ulcers represent a significant cost to public health and adversely affect patients’ quality of life.11
The link between poor protein intake and skin damage involves reduced nutrient availability for tissue maintenance and repair, which reduces skin resistance. Suboptimal dietary intake negatively affects wound healing and wound strength, collagen synthesis, skin elasticity, and cellular turnover.
1. Annuario Statistico Italiano. Rome, Italy: November 2000. 2. Mowé M, Bøhmer T. The prevalence of undiagnosed protein-calorie undernutrition in a population of hospitalized elderly patients. J Am Geriatr Soc. 1991;39(11):1089–1092. 3. Pearson JM, Schlettwein-Gsell D, Brzozowska A, van Staveren WA, Bjørnsbo K. Life style characteristics associated with nutritional risk in elderly subjects aged 80–85 years. J Nutr Health Aging. 2001;5(4):278–283. 4. Thomas DR. Improving outcome of pressure ulcers with nutritional interventions: a review of the evidence. Nutrition. 2001;17(2):155-156. 5. Mathus-Vliegen EM. Old age, malnutrition, and pressure sores: an ill-fated alliance. J Gerontol A Biol Sci Med Sci. 2004;59(4):355–360. 6. European Pressure Ulcer Advisory Panel (EPUAP). Guidelines on treatment of pressure ulcers. EPUAP Rev. 1999;1:31–33. 7. Whittington KT, Briones R. National and incidence Study: 6-year sequential acute care data. Adv Skin Wound Care. 2004;17(9):490–494. 8. Horn SD, Bender SA, Bergstrom N, et al. Description of the National Pressure Ulcer Long-Term Care Study. J Am Geriatr Soc. 2002;50(11):1816–1825. 9. Horn SD, Bender SA, Ferguson ML, et al. The National Pressure Ulcers Long-Term Care Study: pressure ulcer development in long-term care residents. J Am Geriatr Soc. 2004;52(3):359–367. 10. Sari AB, Cracknell A, Sheldon TA. Incidence, preventability and consequences of adverse events in older people: results of a retrospective case-note review. Age Ageing. 2008;37(3):265–269. 11. Fogerty MD, Abumrad NN, Nanney L, Arbogast PG, Poulose B, Barbul A. Risk factors for pressure ulcers in acute care hospitals. Wound Repair Regen. 2008;16(1):11–18. 12. Hommel A, Bjorkelund KB, Thorngren KG, Ulander K. Nutritional status among patients with hip fracture in relation to pressure ulcers. Clin Nutr. 2007;26(5):589–596. 13. Hengstermann S, Fischer A, Steinhagen-Thiessen E, Schulz RJ. Nutrition status and pressure ulcer: what we need for nutrition screening. JPEN J Parenter Enteral Nutr. 2007;31(4):288–294. 14. Allman RM, Laprade CA, Noel LB, et al. Pressure sores among hospitalized patients. Ann Int Med. 1986;105(3):337–342. 15. Patterson JA, Bennett RG. Prevention and treatment of pressure sores. J Am Geriatr Soc. 1995;43(8):919–927. 16. Aimonino Ricauda N, Tibaldi V, Leff B, et al. Substitutive "hospital at home" versus inpatient care for elderly patients with exacerbations of chronic obstructive pulmonary disease: a prospective randomized, controlled trial. J Am Geriatr Soc. 2008;56(3):493–500. 17. Ricauda NA, Bo M, Molaschi M, et al. Home hospitalization service for acute uncomplicated first ischemic stroke in elderly patients: a randomized trial. J Am Geriatr Soc. 2004;52(2):278–283. 18. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffee MW. Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. JAMA. 1963;185:914–919. 19. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9(3):179–186. 20. Pfeiffer E. A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. J Am Geriatr Soc. 1975;23(10):433–441. 21. Fontaine J, Raynaud-Simon A. Pressure sores in geriatric medicine: the role of nutrition. [Article in French]. Presse Med. 2008;37(7-8):1150–1157. 22. Thomas DR, Zdrowski CD, Wilson MM, et al. Malnutrition in subacute care. Am J Clin Nutr. 2002;75(2):308–313. 23. Reynolds TM, Stokes A, Russell L. Assessment of a prognostic biochemical indicator of nutrition and inflammation for identification of pressure ulcer risk. J Clin Pathol. 2006;59(3):308–310. 24. Raynaud-Simon A, Lafont S, Berr C, Dartigues JF, Le Bouc Y. Orosomucoid: a mortality risk factor in elderly people living in the community? Clin Nutr. 2002;21(1):45–50. 25. Kernozek TW, Wilder PA, Amundson A, Hummer J. The effects of body mass index on peak seat-interface pressure of institutionalized elderly. Arch Phys Med Rehabil. 2002;83(6):868–871. 26. Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospital-acquired pressure ulcers and risk of death. J Am Geriatr Soc. 1996;44(12):1435–1440. 27. Culley F. Nursing aspects of pressure sore prevention and therapy. Br J Nurs. 1998;7(15):879–886.
