Pressure ulcer treatments should be re-evaluated, expert says

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Pressure ulcer treatments should be re-evaluated, expert says
Pressure ulcer treatments should be re-evaluated, expert says

Nursing home staff should adopt evidence-based approaches to pressure ulcer prevention and treatment, and significantly more research is needed, a geriatric medicine professor said Saturday.

“We don't know as much as we think we know,” said David Thomas, M.D., FACP, AGSF, GSAF, CMD, a professor at the Saint Louis University School of Medicine, where the International Nursing Home Research Conference was held last weekend. "What we have been facing in the care of pressure ulcers in nursing home is dogma. We desperately need people in nursing homes to do clinical research."

Certain types of wound dressings, nutritional supplements, negative pressure wound therapy and even turning residents haven't proven what consistently can and can't help pressure ulcers in nursing home residents, Thomas said during his presentation Saturday.

What is necessary is to relieve pressure, maintain a moist wound base and relieve pain, he said. Outside of dry gauze, leaders can choose from around 2,800 types of advanced wound dressings, with no evidence that one works better than another, he added.

With regards to mattresses, apart from traditional hospital mattresses, “what should you use, nobody knows,” Thomas said. Meanwhile, there's no evidence that zinc paste is effective; no difference between gold leaf or aluminum foil versus gauze; and no clear evidence that silver works, Thomas said. It's also questionable as to whether debridement is effective.

Finally, with nutrition, there is not evidence that nursing home residents with wounds need special nutrition, and feeding tubes can make the situation worse, he said. Hospitalized nursing home residents with a PEG tube, for example, were 2.27 times more likely to develop a new pressure ulcer.

Thomas noted that different countries have different guidelines for turning residents – the U.S. standard is two hours while the Dutch standard is three hours, and a recent study suggests 2-, 3-, or 4-hour intervals did not appear to make a difference.

There are only 51 papers on pressure ulcers in world literature, Thomas said, and urged leaders at the conference to do pressure ulcer research trials.

That theme resonated throughout the conference, which will next be held in 2015 in Toulouse, France. Around 75 people, who were a mix of medical directors and academic researchers, attended. The conference was sponsored by the International Association of Gerontology and Geriatrics and the Global Aging Research Netwoork.

“There should be evidence for the things we do,” commented John E. Morley, M.D., BCh, the head of the Division of Geriatrics at SLU and Editor-in-Chief of the Journal of the American Medical Directors Association. 

Research projects can be a wonderful opportunity for residents, noted Barbara Resnick, Ph.D, CRNP, FAAN, FAANP, a professor of nursing at the University of Maryland School of Nursing. Some residents may choose to give proxy consent for research projects within advance directives.

Researchers need to make sure they convey to administrators and directors of nursing “what is in it for them,” Resnick advised. Some surveyors like seeing that the nursing home is involved in a study, and researchers can make sure to state that results will be given back to the facility. Even tokens of appreciation, like stickers, can help build the relationship, as well as finding opportunities for staff to be recognized, she noted.

Other presentations at the conference included:

  • Marilyn Rantz, Ph.D., RN, FAAN, a professor at the University of Missouri, presented on “The Technological Nursing Home,” focusing on success in fall reduction and alerting at TigerPlace in Columbia, MO. Wearable sensors “is a short-cut solution to a long-term bigger problem” she said, noting that it's not uncommon to see people fall and a sensor or pendant to be found on the other side of the room. Video surveillance also is unpopular due to residents' privacy concerns. But using sensor networks with silhouette imaging, often with Microsoft Kinect devices installed as motion sensing cameras, has worked, she said.

    "Residents take ownership of the sensor data. They'll say, ‘My daughter can see it but my son can't.' They have been very clear that they don't like video, but these images are fine. … They don't consider silhouette imaging to be privacy violations,” Rantz said.
  • A small Belgium study of people with dementia on low-dose antipsychotics found that abrupt stoppage of the medication is a possible solution, rather than tapering. Withdrawal symptoms peaked on day 3 in the study of 40 people, and 85% of those who stopped abruptly were fine a month later.

    “Abrupt discontinuation appears to be feasible,” said Majda Azermai, Ph.D., a postdoctoral researcher at Ghent University Hospital. Belgium not only has a high rate of antipsychotic use among patients with dementia, but almost all of it is long-term use, she said.

    While tapering is fine, “the conclusions suggest that many older people can be withdrawn without detrimental effects on their behavior.” That's potentially helpful for U.S. clinicians who want to take residents off a low dose of antipsychotics to meet reduction goals.
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