Pressure ulcersBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7539.472 (Published 23 February 2006) Cite this as: BMJ 2006;332:472
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We describe below two simple manoevres which we have found helpful to
prevent and to treat pressure sores,particularly in stroke patients.
Firstly heel sores. Cheap latex rubber gloves are inflated by mouth
and then the necks are tied. It is advisable not to make the inflated
gloves too tense. Six inflated gloves are packed into a small pillow-
case,so as to form a flat cushion. The pillow-case is then closed using
three safety pins. The patient's heel is placed on this soft cushion. When
both legs are paralysed each heel is placed on a separate cushion.
Secondly sacral sores and sores over the greater trochanters. The
great problem is to get the patient to maintain a position on his or her
side as shown in the first figure on page 472 of the BMJ 25 Feb 2006.
Heavy patients have a tendency to gravitate back to lie on their sacrum
despite the use of pillows. In every Arabic home there is a
"marka"(otherwise known as "mesnad") which is a very firm cushion,used to
support the elbow when sitting on the floor. A typical size is 40 x 20 x
20 cm. Because it is square in cross-section it will not roll. It is used
as follows. The marka is placed in a large plastic bag to keep it clean.
When the patient is placed on his or her side the marka is placed fimly
against the back. Then pillows,blankets etc are placed between the marka
and the bed-rail. This trick has proved to be successful in keeping the
body weight off the sacral area.
Competing interests: No competing interests
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
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: No competing interests