Preventing and treating pressure ulcers

Lowering the risk of pressure ulcers

Lying in bed

When people are in bed, they normally move around - even when they're sleeping. But in the later stages of dementia, people may move a lot less and can also develop physical disabilities, so they may be in the same position for substantial periods. This can lead to pressure ulcers developing.

• Try to make sure the person doesn't stay in one position for more than a couple of hours.
• Encourage them to get up during the day and move around as much as possible, either independently or with some help. Consider using a memory aid - eg a timer alarm - to encourage the person to change position independently.
• Ask the nurse or an occupational therapist to show you how to help the person move or transfer between their bed and a chair safely. There are lifting aids available that may help.
• Talk to the nurse about pressure-relieving pads, overlays or mattresses. 

Sitting in a chair or wheelchair

Most people shift around naturally when they are sitting down. But in the later stages of dementia, people are more likely to stay in one position for a long time. This can lead to pressure ulcers developing.

• Encourage the person to change their position in the chair every 15-30 minutes while they're sitting.

• Help them stand up and walk around at least every couple of hours if they are able.
• Ask the community nurse about pressure-relieving seat cushions.
• Ask about being referred to an occupational therapist, especially if the person needs a wheelchair or specialist seating.

Avoiding friction on the person's skin

As people age, their skin becomes more delicate. Even gentle friction on the skin can, over time, increase the risk of pressure ulcers.

• If you help the person to move, be careful not to drag them across the bed or chair.
• Help the person to sit up in the right position while in bed. If they continually have to resist sliding down by trying to push themselves back, this will put pressure or cause friction on the heels and base of the spine.
• Make sure there are no rough seams in their clothes, or anything in their pockets that could rub against the skin.
• Check that bedding is smooth. Wrinkles in the sheets can contribute to pressure ulcers. If the person is in the later stages of dementia, they may not be able to explain easily that they're feeling uncomfortable.
• Consider bed linen and clothing made from natural fibres, such as cotton or linen. These are less likely to cause pressure ulcers than synthetic materials.

General tips for preventing bedsores

• Help the person exercise regularly. Chair-based exercises can help a person to stay flexible and can also relieve pressure. Exercise also improves circulation. For advice on suitable exercise, ask the GP for a referral to a physiotherapist. 
• Try to make sure that the person eats a good balanced diet, with plenty of protein (eg eggs, fish, meat) and fresh fruit and vegetables. They should also drink plenty of fluids. Good nutrition makes the skin healthier and more resistant to ulcers. The GP may offer a referral to a community dietitian. If the person has difficulty swallowing, ask the GP for a referral to a speech and language therapist.
• If the person has problems with incontinence, make sure they don't stay in wet clothes or a wet bed. If skin is in contact with urine for any length of time, it will be more at risk of ulcers. For more information see factsheet 502, Continence and using the toilet.
• Excessive heat and moisture can contribute to pressure ulcers, so try not to let the person become hot and sweaty.
• Avoid close-fitting clothing or tight bedding, especially over the feet.
• Make sure the person is completely dry after a bath or a wash, particularly in the skin folds. Pat them dry - don't rub. 
• Never rub or massage any places where the skin has turned red, as this could cause further damage.

Treating pressure sores

If you have noticed a pressure ulcer at a very early stage (called a category 1 ulcer) the GP will usually arrange for the district or community nurse to assess the person and offer advice.

The nurse can also talk to you about aids to protect the body (such as pressure-relieving pads, special cushions, overlays or mattresses) and how to get hold of them. These aids can help prevent pressure ulcers developing or getting worse. There should be no charge for their use.

Although they are important, they do not replace the need to move and reposition the person. The nurse may also advise on correct sitting or lying positions (eg supporting the feet).

Category 2 pressure ulcers

If the skin has broken (called a category 2 pressure ulcer), the district or community nurse will need to investigate further and ensure that the right treatment is given. As part of this assessment the nurse may take a photograph of the area. This makes it easier to compare the ulcer over time and see whether any treatment is working.

For category 2 ulcers, treatment will generally include cleaning the wound and applying a dressing. The aim is for the ulcer to heal properly and not become a long-term ('chronic') problem, or one which requires hospital treatment. It is essential that the person avoids lying or sitting on the sore area.

Pain relief of pressure ulcers

A pressure ulcer of any type can be extremely painful, so regular pain relief is important. Paracetamol is often very effective for this.

Some pressure ulcers, particularly chronic ulcers, become infected and even more painful. At worst, this can make the person seriously ill with blood poisoning or infection of the bone. Treatment for an infected ulcer is likely to include antibiotics or a special dressing.

Skin changes at the end of life

The skin of a person who is near to the end of their life often shows changes that can't be reversed (eg mottling). These changes are a normal part of the body shutting down. For a person who is within days or weeks of dying, skin changes such as pressure ulcers are often unavoidable, even with the best treatment.

As part of good end-of-life care, the person with dementia (if possible) and their family should be prepared for these skin changes. This will be a difficult time and discussions with the healthcare team may shift away from working to heal any ulcers. Instead, care at end of life is focused on making the person as comfortable as possible, including pain relief.