Spasticity and dementia increase the risk of pressure ulcers

Pressure Ulcers-A Longstanding Problem: A 7-Year Neurorehabilitation Unit Experience of Management, Care, and Clinical Outcomes

BACKGROUND

Neurological disease patients present an increased risk of developing pressure ulcers. The primary aim of this study is to evaluate the incidence and prevalence of pressure ulcers and their impact on length of stay and functional recovery.

METHODS

A retrospective study was conducted in a neurorehabilitation unit over a seven-year period. Data collected include demographic data, length of stay, functional evaluation, risk of pressure ulcers development, nutritional status, and skin. Pressure ulcers were classified according to the European Pressure Ulcer Advisory Panel System.

RESULTS

Data from 816 patients were analyzed. On admission, the authors found 236 pressure ulcers in 131 patients (about 16%), divided into stage I (25%), stage II (50%), and stage III-IV (25%). The most common sites were the heel (36%) and sacrum (29%). Among the risk factors for the development of pressure ulcers, malnutrition played a significant role, with approximately 76% of patients with pressure ulcers having mild to moderate malnutrition.

CONCLUSION

The presence of pressure ulcers seems to have a negative impact on the functional recovery of patients, as shown by the outcome scales and the average length of stay: 51 days versus 36 days (p < 0.01).

Chronic wounds in persons living with dementia: An integrative review

BACKGROUND

Persons living with dementia (PLWD) are at risk for chronic wounds; however, they are rarely included in research.

OBJECTIVES

To inform practice and research directions, the aim of this integrative review was to identify and synthesise previous knowledge about the characteristics of chronic wounds in PLWD, in terms of chronic wound types, prevalence, setting and interventions.

DESIGN

A literature search was conducted for publications in English using PubMed, Web of Science and CINAHL. The minimum information required for inclusion was how many PLWD enrolled in the study had wounds.

METHODS

This integrative review followed the Whittemore and Knafl methodology. Data extraction and synthesis were guided by a directed content analysis, with a coding structure based on an initial review of the literature.

RESULTS

Thirty-six articles met the inclusion criteria. The majority were missing characteristics of PLWD including severity of dementia and race/ethnicity/nationality, and none mentioned skin tone. Most focused on pressure injuries in the nursing home and acute care setting. Few included information on interventions. Only one discussed challenges of wound care for a PLWD exhibiting aggression.

CONCLUSION

There is a gap in the literature regarding PLWD and chronic wounds other than pressure injuries that are common in older adults (e.g. diabetic foot ulcers, venous leg ulcers). Research is warranted among those PLWD who live alone and those who receive wound care from family caregivers to understand experiences. Knowledge can inform the development of future novel interventions for wound healing. Future research is needed regarding chronic wounds in those who exhibit behavioural and psychological symptoms of dementia.

RELEVANCE TO CLINICAL PRACTICE

Nurses that care for chronic wounds in PLWD can contribute their knowledge to include information in guidelines on best care practices and contribute their perspective to research teams for future research.

The influence of anaemia on pressure ulcer healing in elderly patients

Anaemia is a common and multifactorial blood disorder in elderly individuals. This condition may be a significant barrier to pressure ulcers healing as it is associated with a decreased level of oxygen being supplied to body tissues. Some nutritional deficiencies such as iron, vitamin B12 and folate may also cause anaemia and have a negative impact on pressure ulcer healing. An increased iron demand in hard-to-heal pressure ulcers is a significant factor associated with the risk of anaemia of chronic disease in elderly patients. Anaemia screening and correction may need to be considered as well as iron supplementation if required in pressure ulcer prevention and management.

Healing hand ulcers caused by focal spasticity

Spasticity is a common manifestation of many upper motor neuron lesions such as stroke, traumatic brain injury, and multiple sclerosis. In some cases, spastic fingers in the hand press hard into the palm, resulting in skin breakdown and atypical pressure ulcerations. We treated 10 such patients living in the nursing homes with long-standing treatment-resistant hand ulcers in our spasticity clinic first, with Botulinum toxin A (BoNTA) injection into the spastic muscles followed by dressing, splinting, and hand therapy. These ulcers failed to respond to standard treatment, causing significant pain, offensive smell, increased carer burden, and difficulty in maintaining hygiene as hands could barely be opened for dressing and therapy. We noted complete healing of ulcers with significant improvement in the following outcome measures-Modified Ashworth Scale for spasticity, Visual Analog Scale for pain, pressure ulcer grading for the ulcers, Fingertip to Palm distance for hand opening, Carer Burden Scale, and in the Goal Attainment Scale pre, 4 weeks, and 3 months postinjection with P values of .003, .003, .004, .005, .004, and .004, respectively. Reducing spasticity with BoNTA should be the first step in treating hand ulcerations caused by focal spasticity, followed by dressing, splinting, and hand therapy.

Prevalence of Spasticity in Nursing Home Residents

OBJECTIVES

To determine the prevalence, rate of underdiagnosis and undertreatment, and association with activities of daily living dependency of spasticity in a nursing home setting.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

This study is an analysis of a deidentified data set generated by a prior quality improvement project at a 240-bed nursing home for residents receiving long-term care or skilled nursing care services.

METHODS

Each resident was examined by a movement disorders specialist neurologist to determine whether spasticity was present and, if so, the total number of spastic postures present in upper and lower limbs was recorded. Medical records, including the Minimum Data Set, were reviewed for neurologic diagnoses associated with spasticity, activities of daily living (ADL) dependency, and prior documentation of diagnosis and past or current treatments. Ordinary least squares linear regression models were used to evaluate the association between spasticity and ADL dependency.

RESULTS

Two hundred nine residents (154 women, 81.9 ± 10.9 years) were included in this analysis. Spasticity was present in 22% (45/209) of residents examined by the neurologist. Only 11% of residents (5/45) had a prior diagnosis of spasticity and were receiving treatment. Presence of spasticity was associated with greater ADL dependency (χ² = 51.72, P < .001), which was driven by lower limb spasticity (χ² = 14.56, P = .006).

CONCLUSIONS AND IMPLICATIONS

These results suggest that spasticity (1) is common in nursing homes (1 of 5 residents), (2) is often not diagnosed or adequately treated, and (3) is associated with worse ADL dependency. Further research is needed to enhance the rates of diagnosis and treatment of spasticity in long-term care facilities.

Dichotomy in Fatal Outcomes in a Large Cohort of People Living with HTLV-1 in São Paulo, Brazil

Background: Despite its relatively low incidence of associated diseases, Human T-cell Leukemia Virus-1 (HTLV-1) infection was reported to carry a significant risk of mortality in several endemic areas. HTLV-1-associated diseases, adult T-cell leukemia/lymphoma (ATLL) and HTLV-1-associated myelopathy/tropical spastic paraperesis (HAM/TSP), as well as frequent coinfections with human immunodeficiency virus (HIV), hepatitis C virus (HCV), and Strongyloides stercoralis were associated to increased morbidity and mortality of HTLV-1 infection. Objective: To determine the mortality rate and its associated variables from an open cohort started in July 1997 at the HTLV Clinic, Emilio Ribas Institute (IIER), a major infectious disease hospital in São Paulo, Brazil. Methods: Since inception up to September 2018, we admitted 727 HTLV-1-infected individuals, with a rate of 30–50 new admissions per year. All patient data, including clinical and laboratory data, were regularly updated throughout the 21-year period, using a dedicated REDCap database. The Ethical Board of IIER approved the protocol. Results: During 21 years of clinical care to people living with HTLV-1 in the São Paulo region, we recruited 479 asymptomatic HTLV-1-infected individuals and 248 HAM/TSP patients, of which 632 remained under active follow-up. During a total of 3800 person-years of follow-up (maximum follow-up 21.5 years, mean follow-up 6.0 years), 27 individuals died (median age of 51.5 years), of which 12 were asymptomatic, one ATLL patient and 14 HAM/TSP patients. HAM/TSP diagnosis (but neither age nor gender) was a significant predictor of increased mortality by univariate and multivariate (hazard ratio (HR) 5.03, 95% CI [1.96–12.91], p = 0.001) Cox regression models. Coinfection with HIV/HCV was an independent predictor of increased mortality (HR 15.08; 95% CI [5.50–41.32]; p < 0.001), with AIDS-related infections as a more frequent cause of death in asymptomatics (6/13; p = 0.033). HIV/HCV-negative fatal HAM/TSP cases were all female, with urinary tract infection and decubitus ulcer-associated sepsis as the main cause of death (8/14, p = 0.002). Conclusions: All-cause mortality among people living with HTLV-1 in São Paulo differs between asymptomatic (2.9%) and HAM/TSP patients (7.3%), independent of age and gender. We observe a dichotomy in fatal cases, with HAM/TSP and HIV/HCV coinfection as independent risk factors for death. Our findings reveal an urgent need for public health actions, as the major causes of death, infections secondary to decubitus ulcers, and immune deficiency syndrome (AIDS)-related infections, can be targeted by preventive measures.

Spasticity and dementia increase the risk of pressure ulcers

The aim of this study was to identify and characterise the association between the prevalence of pressure ulcers, spasticity levels, and advanced dementia in disable elderly patients. Data were obtained from the patient medical files. Patients were hospitalised in the geriatric skilled nursing department. A total of 40 frail elderly patients, bedbound and suffering from advanced chronic diseases, advanced dementia, and high-grade pressure ulcers, were examined. Pressure ulcer grades and spasticity in advanced dementia versus non-dementia patients were evaluated. Logistic regression indicated that only advanced dementia and spasticity were significantly associated with the development of pressure ulcers versus those without dementia or without spasticity. Patients with advanced dementia displayed a significantly higher prevalence of severe spasticity. In multivariate logistic regression analyses, spasticity was significantly associated with pressure ulcers. The strong association of spasticity with the onset of pressure ulcers in advanced dementia should encourage clinicians to implement preventative measures to delay the onset of pressure ulcers.