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Study of an old Man's Profile - Galleria degli Uffizi - Firenze
Pressure ulcers: old and new Torna agli editoriali

di
A.G. Cattaneo, DBSM, via J-H Dunant 3, 21100 Varese

Pressure ulcers have been an annoying wound for the humans from very ancient times. Firstly described in the medical literature in the 16th century, they were probably represented by the popular art very earlier. Clay models conserved in Dijon, France, represent feet treated with a sponge on the heel, a typical site for pressure ulcers; they were left as "ex voto" near the Seine sources, a holy site for the ancient Celtic population living in France one or two century BC.
Today, despite the great improvement of knowledge and technology, pressure ulcers continue to represent, as a frequent complication of major invaliding conditions, not only an additional font of distress for the patient and a source of frustration for the caregiver, but even an economical nightmare for the sanitation administrators.

Pressure ulcers typically develop in bedridden patients, in which the main risk factor seems to be the prolonged local pressure with concomitant poor blood supply, nerve injury, loss of sensitivity and friction. Other well recognized risk factors are skin moisture and malnutrition. Compromised trophic texture, arterial and venous blood supply, sensorial and sympathetic nerve regulation, immune system responses represent additional risk factors frequent in older persons. The role of endothelial dysfunction is possible, but not even proven.

Bedridden patients are more frequent between veterans, when the inability to actively move can be due to a number of causes. Major bone fractures (hip fracture being an example), ictal events, acute illness in frail individuals, loss of consciousness or simply the weakness accompanying the extreme aging are among them. The frail oldest person is frequently unable to properly inspect his body, communicate the distress and maintain an adequate personal hygiene while incontinent. Malnutrition, with insufficient intake of essential factors, amino acids, lipids, vitamins and oligoelements, is also more frequent than in younger individuals, due to poverty, psychological or cognitive reasons, neglect or inadequate care.

Pressure sores develop with extreme ease and rapidity, but the healing process is comparatively long, fastidious and charged with high frequency of reactivation. These wounds are quite frequent in all ages, when favouring conditions develop; in people aged >65 years they affect about 50% of those requiring geriatric or hospital care. The existence of supranational observatories devoted to this topic (like the National Pressure Ulcer Long-Term Care Study in U.S.A., or the Pan-European Pressure Ulcer Study) witness for the great importance of finding a better solution.

From year 2000 three organisms operating in European countries (the European Pressure Ulcer Advisory Panel, EPUAP, the Royal College of Nursing, RCN, in UK, and the Deutsches Netzwerk für Qualitätsentwicklung in der Pflege, DNQP, in Germany) developed independent guidelines, partially uniformed after periodical updating. The common aim was the development of standardized classification system and preventive programs useful for learning, research, practice and communications. Similar programs have been developed in USA and other non-European countries.

The classification system of the EPUAP, and similarly that used in the USA, define 4 grades of lesion, from non blanchable erythema of intact skin (grade 1) up to skin loss (even partial) with damage of the fascia and of the supporting structures (grade 4). The intermediate grades include superficial ulcers, with damage of epidermis, dermis or both (grade 2) and full thickness skin loss with damage of subcutaneous tissues but not involving the fascia (grade 3). Photographic atlas have been proposed and used.
The preventive programs promoted by the EPUAP, the RCN and the DNQP show minor differences, and include risk and risk factors assessment with tested scales, pressure relief obtained with repositioning and use of pressure reducing devices when adequate, regular skin inspection and early recognition of lesions (grade 1), education and training of both the patient and the care giver (at home and at the hospital).

Recent papers evaluating the fields included in the programs demonstrate the excellence of a standardized method of classification combined with a careful educational program in improving prevention of lesions and recurrences.

Individualized education given to old, at risk subjects added to structured and frequent contact (by phone) with old patients discharged after surgery for pressure ulcers significantly reduced recurrence episodes, or prolonged the disease free period. Whenever possible, patients should be educated to inspect their skin and recognize early signs of lesions, and to correctly care their hygiene and nutritional needs.
Not only the patient should be educated to manage and know the risk of chronic wounds: better care and prevention have been obtained by specific education programs addressed to the medical staff on the epidemiology, pathophysiology and treatment strategies of pressure ulcers.
It has been demonstrated that reduction of nurse staffing results deleterious not only for the patient outcome, but even for the social costs linked to the length of treatment, frequency of recurrences and complications. However, the most skilled care was not necessarily linked with the educational degree of the nurse, basic care givers with long experience in the field scoring best than those with higher qualifications.

Early diagnosis and recognition of at risk conditions is mandatory for efficient prevention and cure: to limit the measures for pressure relief to the subjects presenting grade 1 lesions seems to be a good preventive measure, not enhancing the risk for advancing of the lesion to more serious stages and sparing the need for pressure-reducing mattress means and the efforts in periodically repositioning the patient. The efficacy of this measure is limited by the frequency of misdiagnosing moisture lesions from blanchable erythema, a frequent mistake.

Unfortunately, the reliability of inter-observer in classifying chronic skin wounds remained low until recently (Beeckman et al, 2007, Journal of Advanced Nursing 60: 682-691), and the high frequency of misdiagnosing moisture lesions from blanchable erythema greatly limited this simple measure.

Needs for better clarify and disseminate the classification system, seems to be desirable, due to the complexity of the field.

Once developed, the pressure ulcers should be treated. The basics measures for this treatment can be summarized in hygiene, pressure relief, wound dressing and sterility, pain relief, surgical debridments and daily curettage when needed. A diffuse practice, massaging with or without lenitive creams the skin presenting signs of grade 1 lesion, does not seem to be very efficient in comparison with pressure relief alone.
The old and the new in all these fields mix together, fomenting the hope of more efficient cure which remains to be unequivocally demonstrated. A large number of devices are continuously proposed to help the healing process and to reduce the progression and recurrences of the lesion. New mattress are claimed to have superior quality in pressure relief, wound dressing adsorbed with new substances (or old, and revisited) or completely new textiles seems accelerate complete healing, devices proposed to help the healing process through polarized light, or low and ultra low pulsed electric current, or even low frequency ultrasounds can be of great benefit.

While of great interest, all trials testing new therapeutic methods and devices should be submitted by thorough supervision by the organism competent for the territory before being divulge as very efficient.

Take several opposite example, to be clear.
Among old remedies, the resin of the Norway spruce, used in folk medicine, seemed to retain superior quality in comparison with dressing with hydro colloid polymers: sterility was more rapidly and more frequently obtained, and healing occurred in 92% of patients treated with resin (vs 44% with hydro colloid). The results were recently obtained in a controlled trial performed in Finland (Br J Dermatol 158:1055-62, 2008). Analogously, honey dressing, another traditional mean of cure, performed better than conventional dressing in a trial performed in Turkey (J Wound Ostomy Continence Nurs 34:184-190, 2007).

The same can be true when very innovative means of cure are proposed, like nanotechnologies applied to the silk peptides crystallization in aqueous environments. The products are poorly expensive, highly resistant and biocompatible surfaces for controlled drug release and wounds dressing (J Control Release 121:190-9, 2007; J Nanosci Nanotechnol. 7:3888-91, 2007.)
While published in peer-reviewed journals, these results can be surprising, and however it should be comforting if their superiority should be stated by unbiased, standardized methodologies.

In conclusion, it should be a good practice if private as well as national and public organisms devoted to the care and welfare of older persons will recognize and adopt the lines suggested by the recognized organism active locally (the EPUAP in Italy). The policy of promote permanent educational observatory and trials seems to be the most desirable occurrence. Improvement in diagnosis and in treatment skills should be achieved. Very fastidious chronic wounds, those poorly healing or frequently recurrent should be considered as the spy of underlying conditions, from local ischemia to neoplasms or metabolic diseases. Carefully investigation and adequate treatment follow even in extreme aged persons.

Well established practice should be maintained without hardy change, if this last has not been seriously proven by local and multi-centre trials; however the news in the field must be know by the administrators and critically divulged among the care givers.

Anna Giulia Cattaneo, DBSM, Università dell'Insubria, Via J-H Dunant,3 - 2100 Varese

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