Practice ABC of wound healing

Pressure ulcers

BMJ 2006; 332 doi: (Published 23 February 2006) Cite this as: BMJ 2006;332:472

Pressure ulcers in advanced dementia may need a different approach.

Dear Sirs,

Joseph E Gray et al's review makes general recommendations (standard
care) for caring patients with pressure ulcers, which in our point of view
could be misleading for professionals caring for patients with pressure
ulcers and a palliative condition as is advanced dementia.

Advanced dementia has an ominous prognosis, with a high six month
mortality rate(1). A grade 4 pressure ulcer could take 3-5 months to
heal(2). After doing an extensive literature search we haven't found any
study published about the rate of ulcers healed receiving standard care in
patients with advanced dementia, so we looked at our local data searching
for answers.

On January 2006 we made a retrospective review of all patients with
advanced dementia attended between September 2003 and September 2004 in
our unit. Our patients received some components of the standard care
(there were not a specific policy of using a palliative approach):

135 patients with advanced dementia were attended. 64 patients
(47,4%) had one or more pressure ulcers grade 3 or 4. 47 of those 64
(73,4%) died during the following months until January 2006. 42 patients
of those 47 (89,3%) died with one or more ulcers not healed.

These striking data highlight the main goal of care of pressure
ulcers in advanced dementia: palliation of symptoms instead of trying to
heal the ulcers with an aggressive approach. We think that only
interventions and dressings directed to controlling pain, malodour, and
the excessive exudates should be carried out in these patients(3). This is
very important because there are a lot of dressings but only a limited
evidence of the effectiveness of them(4). This approach would also reduce
nursing time and the high costs of healing a grade 4 pressure ulcer

In that way, several interventions should be discouraged in patients
with advanced dementia and pressure ulcers:

1) Supplementary feeding (via nasogastric tube or PEG) should not be
systematically recommended in these patients as it has been proved not
being useful to heal the ulcers in advanced dementia (5).

2) Surgical debridements or surgical repairs should not be
recommended in these patients, due to the potential increase of suffering
and the high rate of recurrence(6).

3) Besides, there is no clear evidence of the effectiveness of
support surfaces in advanced dementia:
-There are not studies of the effectiveness of support surfaces to
prevent/treat pressure ulcers in advanced dementia.
-What is the effectiveness of support surfaces compared to standard care
(frequent repositioning and a good care of the skin)?
-Support surfaces do not reduce the necessity of doing regular
repositioning to the patients, so they do not reduce the burden of care in
the familiar caregiver.
-Do support surfaces reduce pain, number of infections, nursing time, or

4) Long admissions in hospitals to aggressively treat pressure ulcer
infection are not warranted.

Alberto Romero Alonso MD,

(1) Mitchell SL, Kiely DK, Hamel MB. Dying with advanced dementia in
the nursing home. Arch Intern Med 2004; 164(3):321-326.

(2) Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in
the UK. Age Ageing 2004; 33(3):230-235.

(3) de Laat EH, Scholte op Reimer WJ, van Achterberg T. Pressure
ulcers: diagnostics and interventions aimed at wound-related complaints: a
review of the literature. J Clin Nurs 2005; 14(4):464-472.

(4) Bouza C, Munoz A, Amate JM. Efficacy of modern dressings in the
treatment of leg ulcers: a systematic review. Wound Repair Regen 2005;

(5) Finucane TE, Christmas C, Travis K. Tube feeding in patients
with advanced dementia: a review of the evidence. JAMA 1999; 282(14):1365-

(6) Kuwahara M, Tada H, Mashiba K, Yurugi S, Iioka H, Niitsuma K et
al. Mortality and recurrence rate after pressure ulcer operation for
elderly long-term bedridden patients. Ann Plast Surg 2005; 54(6):629-632.

Competing interests:
None declared

Competing interests: No competing interests
27 February 2006
Alberto Romero Alonso MD
Internal Medicine Specialist
Ángel Rodríguez Hurtado RN, Ernesto de Villar Conde MD, PhD
Servicio de Medicina Interna (UCA), Hospital El Tomillar, 41700, Seville, Spain.
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