Assessment and management of chronic pressure ulcers in the elderly

A pressure injury is localised damage to the skin and underlying tissue, usually over a bony prominence such as the sacrum or heel. Pathy's prefers "pressure injury" over "pressure ulcer" because not every lesion is an open ulcer.

A chronic pressure ulcer is one that fails to progress through orderly healing. A useful benchmark: the wound should be 20–40% smaller by week 4 if it is going to heal by week 12. Failure to shrink means the diagnosis and the underlying factors must be re-examined.

Three mechanical forces produce the injury: pressure, shear (head-of-bed elevation makes the torso slide and drags subcutaneous tissue over the sacrum) and friction. Moisture from sweat, urine and faeces compounds all three. More than 90% occur in the lower body – sacrum and coccyx, ischial tuberosities, greater trochanter and heels.

Incidence varies widely by setting: acute care 0.4–38%, long-term care 2.2–23.9%, home care 0–17%. About 25% of pressure ulcers are acquired intra-operatively, because neither position nor duration of surgery can be altered.

Advanced age is NOT an independent risk factor. The risk comes from the impairments that cluster in old age – immobility, poor nutrition and fragile skin. This is a favourite examiner point.

Established risk factors: bed- or chair-bound, unable to reposition without help, difficulty with ambulation, history of stroke, faecal incontinence, low body weight, lymphopenia, difficulty with independent feeding, impaired nutritional intake, non-blanchable erythema of intact skin (a Stage 1 injury), and dry sacral skin.

Risk-assessment tools in use: Braden, Norton and Waterlow scales. The recommendation is to apply a tool on admission and repeat regularly. Evidence that the scales themselves improve outcomes remains uncertain – they supplement, not replace, structured skin inspection.

Stage 1: intact skin with non-blanchable erythema. Stage 2: partial-thickness loss with exposed dermis – blister, abrasion or shallow ulcer. Stage 3: full-thickness loss into subcutaneous fat, down to but not through fascia, often with undermining. Stage 4: extends through deep fascia – muscle, tendon or bone visible, undermining and sinus tracts common. Use Arabic numerals, not Roman.

Two additional categories when depth cannot be seen: Unstageable – base obscured by slough or eschar (stage it once debrided); and Deep tissue pressure injury (DTPI) – skin intact but deep red, purple or maroon, or a haemorrhagic blister, indicating damage in deeper tissue.

Medical device–related pressure injuries (urinary catheter, rectal tube, oxygen tubing) conform to the shape of the device and are staged. Pressure injuries on mucous membranes are documented but NOT staged.

Never reverse-stage. A healing Stage 4 does not become a Stage 2 – the lost tissue is replaced by scar, not by fat and muscle. Monitor healing instead with the PUSH tool (Pressure Ulcer Scale for Healing), which scores three components – size, exudate amount and tissue type – and is validated and sensitive to change.

Document every ulcer under seven headings: (i) type, duration and setting in which it arose; (ii) length × width × depth in cm; (iii) colour as percentages – red granulation, yellow slough, black eschar; (iv) exudate – serous, serosanguinous, sanguineous or purulent; (v) odour, assessed only after thorough cleaning; (vi) periwound skin – viable, macerated, inflamed or hyperkeratotic; (vii) undermining and sinus tracts. Add a pain score.

Diagnosing infection in a chronic wound: increasing pain is the single best clinical predictor (likelihood ratio 11–20). The "classic signs" – purulent exudate, erythema, heat, oedema – and foul odour do not reliably predict infection. When infection is suspected, take a quantitative swab using the Levine technique: rotate the swab over a 1 × 1 cm area for five seconds with enough pressure to express fluid from within the tissue. A positive result gives LR 6.3; a negative result LR 0.47.

Suspect osteomyelitis in any non-healing Stage 4 ulcer: probe-to-bone, plain radiograph, MRI. Bone or deep tissue biopsy culture – including anaerobic culture – directs therapy far better than surface swabs.

Managing the underlying contributing factors matters more than any dressing or adjunctive therapy. Offload pressure, correct nutrition, control incontinence, treat pain, restore mobility, review sedatives and restraints. Most trials unfortunately study dressings, not causes.

Support surfaces and repositioning: reposition at least 2-hourly on a standard mattress and at least 4-hourly on a pressure-redistributing mattress. Powered mattresses have not been shown to heal ulcers better than non-powered ones despite far greater cost; a disciplined turning schedule is a cheaper alternative.

Local wound care: no single dressing has been shown superior to another in well-designed trials. Standard care of a healable ulcer must satisfy three criteria – moisture balance, bacterial balance and debridement. Choose the dressing on cost, ease of use, goals of care and patient comfort.

Debridement of necrotic tissue by autolytic, enzymatic/chemical, mechanical, sharp or surgical means; irrigate two to three times daily; undermine and remove eschar that conceals infected tissue. Exception: leave stable, dry, adherent heel eschar alone in a limb with peripheral arterial disease – it is a biological dressing.

Antibiotic discipline: do not treat colonisation. In Stage 3, treat only proven cellulitis, osteomyelitis, bacteraemia or sepsis; routine surface cultures are unhelpful because they grow mixed flora and miss anaerobes, and reflect colonisation. In Stage 4, systemic antimicrobials are often required; for a septic patient use broad-spectrum cover for anaerobes, Gram-negative organisms and Staphylococcus aureus, then de-escalate on tissue culture.

Nutrition: refer to a dietitian. Targets are 30–35 kcal/kg/day energy, 1.0–1.5 g/kg/day protein and 1 mL fluid per kcal. Supplementation improves healing chiefly in those who are already malnourished; protein supplements may help long-term-care residents. Check haemoglobin (g/dL) and serum albumin (g/dL) as markers of the overall nutritional state.

Adjunctive therapies – negative-pressure wound therapy, hyperbaric oxygen, laser, electrotherapy, electromagnetic therapy, therapeutic ultrasound: no good evidence that any of these improve pressure injury healing. Platelet-derived growth factor has some supporting evidence but not enough for routine use.

Surgery: plastic surgical consultation for selected Stage 4 lesions – flap or graft closure – but only when the patient is fit, nutrition is corrected and, above all, the cause has been removed, otherwise the flap breaks down.

Non-healable ulcers and skin failure: not all pressure injuries are preventable. Where the underlying conditions are irreversible or the goals of care are comfort, shift the aim from healing to reducing infection risk and controlling pain. Wounds that appear and worsen over bony prominences during overall terminal decline are termed skin failure rather than pressure injury.

Pain is managed at every stage – background pain and procedural pain at dressing change. Use topical anaesthesia, pre-emptive analgesia and the WHO ladder with geriatric dose adjustment.

International Guideline, 4th edition (2025) – NPIAP / EPUAP / Pan Pacific Pressure Injury Alliance, edited by Emily Haesler, replacing the 2019 third edition. Built with GRADE and evidence-to-decision frameworks by more than 240 clinical experts and consumer representatives, and released as staged online chapters (prevention chapters first from February 2025, treatment recommendations from late 2025) rather than a single printed book.

Sub-epidermal moisture (SEM) measurement and skin temperature are now recommended as adjuncts to visual skin assessment for detecting Stage 1 injury and deep tissue injury before they are visible, particularly at the sacrum. This matters especially in darkly pigmented skin, where non-blanchable erythema is easily missed – highly relevant to Indian practice.

Prophylactic dressings have moved into guideline recommendations: a soft silicone adhesive multilayered foam dressing is suggested as an adjunct to heel elevation and repositioning for heel injuries, and over the sacrum and trochanters in at-risk hospitalised patients (BORDER trial lineage). NPIAP/EPUAP have launched the Prophylactic Dressing Standards Initiative (PDSI) because no accepted standard yet exists for testing dressings used on intact skin.

SPIPP (Standardized Pressure Injury Prevention Protocol) – a five-item checklist now widely used as an audit tool: validated risk assessment, prophylactic dressings, beds and support surfaces, repositioning systems, and skin care.

Device-related injuries have their own 2025 chapter, extending the concept beyond medical devices to non-medical items – phones, remote controls, call bells, jewellery, spectacles and bed clutter left in contact with skin.

Wound Canada 2025 Best Practice Recommendations reinforce the 20–40% area reduction at week 4 benchmark and formal reclassification of a stalled wound as non-healing or non-healable by the interprofessional team.

NPHCE provides geriatric wards at district hospitals and regional geriatric centres, where pressure injury prevention should be an audited quality indicator.

Kerala's community palliative care network – ward-level nurse-and-volunteer home-care teams under the state palliative care policy – remains India's best-developed model for the bedbound elderly, and pressure sore care is one of its core deliverables. Vayomithram mobile units add urban outreach.

AB-PMJAY and the Ayushman Vay Vandana Card (universal for those aged 70 and above) cover hospitalisation, debridement and flap surgery, but not chronic outpatient dressings.

Rashtriya Vayoshri Yojana and ADIP–ALIMCO supply wheelchairs, walkers, commodes and other assistive devices free or subsidised to eligible senior citizens – central to offloading and mobilisation.

Practical realities: alternating-pressure mattresses are frequently unavailable; disciplined 2-hourly turning by a trained family caregiver, cotton draw sheets, a well-padded water or air mattress, and daily heel inspection deliver most of the benefit. Vegetarian diets often fall short of the 1.0–1.5 g/kg protein target – counsel on dal, curd, paneer, eggs and locally affordable protein sources against the ICMR-NIN 2024 reference values.

"Pressure injury" is preferred over "pressure ulcer" because not all lesions are open ulcers.

Advanced age is not an independent risk factor for pressure injury development.

Dry sacral skin and lymphopenia are both recognised independent risk factors.

Deep tissue pressure injury = intact skin that is deep red, purple or maroon, or a haemorrhagic blister.

Unstageable = base hidden by slough or eschar; stage it after debridement.

Mucous membrane pressure injuries are documented but never staged.

Reverse staging is inaccurate; use the PUSH tool (size, exudate, tissue type).

The best clinical predictor of infection in a chronic wound is increasing pain.

Levine technique: rotate a swab over 1 × 1 cm for 5 seconds with pressure enough to express tissue fluid.

No single dressing is superior; aim for moisture balance, bacterial balance and debridement.

Adjunctive therapies including hyperbaric oxygen have no good evidence of improving healing.

About one-quarter of pressure ulcers are acquired in the operating theatre.

Skin failure describes wounds appearing over bony prominences during terminal decline.

The 2025 fourth-edition International Guideline is a GRADE-based, staged online release.