An overview of co-morbidities and the development of pressure ulcers among older adults.

BACKGROUND: The prevalence of pressure ulcers particularly in the frail older adult population continues to be high and very costly especially in those suffering from chronic diseases and has brought a higher awareness to comprehensive, preventive and therapeutic measures for treatment of pressure ulcers. Internal risk factors highlighted by comorbidities play a crucial role in the pathogenesis of pressure ulcers. MAIN BODY: Focusing on the impact of common chronic diseases (comorbidities) in aging on pressure ulcers (e.g., cardiovascular diseases, diabetes, chronic pulmonary diseases, renal diseases and neurodegenerative disorders) and the significant complicating conditions e.g., anemia, infectious diseases, malnutrition, hospitalization, incontinence and polypharmacy, frailty and disability becomes important in developing a more complete, inclusive and multidisciplinary approach to prevention of PU in older patients. OBJECTIVE: To describe chronic and acute conditions which are risk factors in elderly patients for developing PU. METHODS: We present an overview of comorbidities seen with PU in three diverse patient locations. The inclusion criteria are sites (community, acute hospital and long term facilities), older patients, chronic diseases and pressure ulcers grade 2 and over. Using a recently developed conceptual framework accepted by European and National Pressure Ulcer Advisory Panels, we examined chronic diseases to identify the risk factors of chronic conditions and complicating conditions which potentially influence risk for PU development. CONCLUSION: Multiple chronic diseases and complicating factors which associated with immobility, tissue ischemia, and undernutrition are caused to PU in community settings, hospitals, and nursing facilities.

The Effect of Pressure Ulcers on the Survival in Patients With Advanced Dementia and Comorbidities.

BACKGROUND/STUDY CONTEXT: The mortality rates for many leading causes of death have declined over the past decade. Advanced dementia with comorbidities has steadily increased to become one of the leading causes of death in the elderly population. Therefore, this study examined the effect of pressure ulcers on the survival time of patients with advanced dementia and comorbidities. METHODS: Data were reviewed from all the files of 147 patients hospitalized over a period of 3½ years. Ninety-nine tube-fed patients suffering from advanced dementia were assessed; 72 (66.5%) had pressure ulcers and 27 (33.5%) were without pressure ulcers at admission. Logistic regression analysis was used to estimate the odds ratio and 95% confidence intervals for pressure ulcers group versus non-pressure ulcers group. Unadjusted Cox model and Cox proportional hazards model were used to assess the hazard ratio for pressure ulcers and the association between pressure ulcers and survival time, respectively. Kaplan-Meier model was used to visually confirm the existence of proportional hazards of pressure ulcers on survival. RESULTS: The median survival of advanced dementia patients with pressure ulcers was significantly shorter, compared with those without pressure ulcers (96 vs. 863 days). Significant lower hemoglobin and serum albumin levels were found in the patients with pressure ulcers. CONCLUSION: Advance dementia and pressure ulcers in the same patient results in earlier mortality. Advanced dementia patients with pressure ulcers had significantly lower survival expectancy in comparison with similar patients without pressure ulcers. Clinical and ethical implications are discussed.

A comparative, descriptive study of systemic factors and survival in elderly patients with sacral pressure ulcers.

Sacral pressure ulcers (PUs) are a serious complication in frail elderly patients. Thin tissue in the sacral area, low body mass index, and anatomical location contribute to the development of sacral PUs. A comparative, descriptive study was conducted to identify patient systemic factors associated with sacral PUs and to compare survival time in patients with and without PU. All consecutive patients with PUs (n = 77) and without sacral PUs (n = 53) admitted to the skilled nursing department of a geriatric hospital in Jerusalem, Israel between July 1, 2008 and December 31, 2011 were eligible to participate. Charts of previously admitted patients were abstracted and patients were prospectively followed until discharge, death, or the end of the study. Patient demographics, comorbidities, nutritional status, physical and cognitive function (measured using the Reisberg's Functional Assessment Staging Tool [FAST], Stages of Dementia of Alzheimer Scale, and the Glasgow Coma Scale), PU status, number of courses of antibiotic treatment during admission, length of hospitalization, and mortality were compared between patients admitted with and without a sacral PU using descriptive and univariate statistics. Logistic regression models were used to estimate the odds ratio (OR) and 95% confidence intervals (CI) for sacral PU versus without PU by study covariate. The association between sacral PU and survival time was assessed using Kaplan-Meier models. Patients with a sacral PU were significantly older (average age 81.60 ±10.78 versus 77.06±11.19 years old, P = 0.02) and had a higher prevalence of dementia (70% versus 30%, P = 0.007), Parkinson's disease (92.3% versus 7.7%, P = 0.03), and anemia (67.7% versus 32.3%, P = 0.06) than patients admitted without a PU. Patients with a sacral PU also had a lower body mass index (23.1 versus 25.4, P = 0.04), and lower hemoglobin (10.54 versus 11.11, P = 0.03), albumin (26.2 versus 29.7, P = 0.002), and total protein levels (61.3 versus 65.7, P = 0.04). In addition, antibiotic treatment was significantly higher in the patients with PU (50.6% versus 28.3%, P = 0.01). Patients with a sacral PU also had significantly lower physical and cognitive functioning scores and their median survival time was 70 days compared to 401 days in the non-PU group (P <0.001). These findings are generally consistent with the literature regarding risk factors for PU development and confirm the need for preventive measures. In addition, clinicians need to address the overall goal of patient care and patient quality of life when considering PU management interventions in this patient population.