Tuesday, August 14, 2012

Bedsores (A Healing without Medication Update)

When I wrote my book Healing without Medication back in 2003, I hadn't had a lot of personal experience dealing with bedsores. I still haven't had a problem with them myself, but my dad did in the last few weeks of his life. If you have bedsores, or if you are concerned for or taking care of a loved one who has bedsores, they can be a really distressing problem. Although I have taken care not to use photographs of especially nasty bed sores, sensitive readers may find images later in this post disturbing.
Bedsores can be hard to look at. That's why I chose an image of a relatively benign bedsore as an illustration for this post. They can look a lot worse than that. But bedsores can also appear harmless at first.

In Stage I of a bedsore, the skin is merely persistently pink. It doesn't blanch white when it is pressed. The bedsore may be itchy, or not, but the skin is still warm to the touch. The first stage of a bedsore might look more like the outer ring of the bedsore in the photo to the left.

In Stage II of a bedsore, the skin skin begins to turn darker red or purple. There may be a blister, and there may be swelling, but the skin over the sore is still intact. There might be a little oozing, or not.

Stage III of a bedsore is a lot more distressing for all concerned. The sore usually has eaten through to the fatty tissue just beneath the skin. By this point, the sore is black, and it may begin to emit a foul odor. With apologies to sensitive readers, but I thought you really need to know what can happen if a bedsore isn't taken care of, I've included a photo of another bedsore at a later stage just after the next paragraph.

Stage IV of the process is even worse. The region of inflammation and tissue destruction extends to muscles, tendons, and joints. Bedsores can even reach bone. The lesion will be black or white, and it usually hurts.
Odor, however, often diminishes.

Bedsores may be accompanied by fever when there is infection, but there often isn't any infection in a bedsore. As I noted in Healing without Medication, most bedsores form on the buttocks, tailbone, shoulder blades, the heel of the foot, or behind the ankle or knee, all places where the weight of the body presses the skin firmly to the bed beneath it. T

his pressure creates a “no-reflow” phenomenon that temporarily cuts off the skin’s blood supply. Injury to skin cells at first only causes an area of redness and irritation. If circulation is not restored over a period of days, however, skin cells die. Bacteria that do not require an air supply can flourish, however, and invade skin, muscle, and bone.

Bedsores can become serious or even life-threatening if they are left untreated. Bedsores are a common health problem in hospitals and nursing homes, although they are a problem in home healthcare, too. According to one report, in the United States approximately 9 percent of all hospitalized patients have bedsores, as do 9 percent of patients in home care and 23 percent of all nursing-home residents. The risk of developing bedsores is greatest in persons who have cardiovascular disease or diabetes, stroke patients, men, and persons who consume limited protein.

One of the best ways to prevent bedsores is to make sure the diet provides complete protein. If you follow a Western or "standard American" diet, it's actually hard to avoid getting too much protein. People of all ages who are confined to bed, however, sometimes either have difficulty biting, chewing, and swallowing, or they develop an aversion to their favorite foods (due to nausea or side effects of drugs) and start getting most of the calories from bland carbohydrate foods.

If you have an elder who tries to live on crackers or cookies, protein deficiency is a real concern. Another important concern for preventing bedsores is making sure the diet provides enough calories. Just because someone is confined to bed doesn't mean she (or he) needs to diet.

The basal metabolism of breathing, pumping blood, and basic tissue repair almost always requires 1,200 calories (kcal) per day. The body can strip out the amino acids alanine and glutamine to make glucose when it doesn't get enough glucose (sugar) from food. Literally burning these amino acids for fuel makes tissue repair impossible.

Getting enough calories, from all sources (carbohydrates/sugars, fat, and protein) helps conserve the amino acids the body has to have to maintain skin and tissues beneath it. Diet also plays a role in treating bedsores.

With good diet, and after taking appropriate measures to relieve the pressure on the skin, a bedsore at stage I may heal in 2–3 days. Deeper stage IV bedsores may require 6 weeks to 3 months. The speed of healing also depends on the patient’s age, overall health, nutrition, and mobility.

Strictly speaking, no scientific study has shown that good nutrition can prevent bedsores, although good nutrition certainly accelerates healing. There isn't any nutritional supplement for bedsores that works like a magic bullet, either, although vitamin C will help. In fact, vitamin C seems to play a special role in the healing of bedsores.

The research on the use of vitamin C in the treatment of wounds I was reading back in 2003 found that it keeps the basal layers of skin from contracting when the upper layers are injured. This allows regrowth of skin with a minimum of scarring. A series of experiments with animals had found that supplementation with relatively high dosages of vitamin C increases the strength of skin growing over the wound and accelerates closure.

Then a clinical trial (with humans, of course) conducted at Austin Health in Burwood, Australia found that a combination of vitamin C, alanine, and zinc supplements accelerated the healing process, and another clinical trial at the Danone Research Center in the Netherlands, published in the journal Nutrition in 2010, reported that a “high protein” meal replacement with a full complement of micronutrients probably works just little better.

If eating enough seemed to be an issue, I'd focus on calories and protein before I gave multivitamins. I wouldn't start handing out alanine supplements (glutamine supplements wouldn't hurt but they aren't really necessary in all but the most protein-deprived diets) or vitamin C and zinc before taking care of calories first.

There is also one natural remedy for the skin that I know works from personal experience, and most hospitals use it, too. It's aloe. Aloe vera gel seems to stimulate wound healing. It doesn't make a dramatic difference. Usually a wound will only heal about 3 days faster with applications of aloe vera gel with every change of dressings than without them. But aloe vera gel may be enough if a bed sore is caught at stage I. 

What else can concerned family members do to prevent bedsores during home health care? Many bedsores can be prevented by using simple measures to relieve pressure and to decrease the skin’s vulnerability to injury. Preventive strategies include:

Inspect the skin at least once a day. Early detection can keep stage I bedsores from progressing.

Relieve pressure on the skin. Change position every two hours when in bed and every hour when seated in a chair. Relieve pressure on the buttocks, tailbone, heels, and back of the knees with a foam egg-crate mattress, water mattress, or sheepskin. If you cannot afford these, try an air mattress.

Use pillows to raise the arms, legs, buttocks, and hips. Reduce friction. Never drag tender skin across the bed sheets.

Encourage the use of a trapeze to lift the body off the sheets or lift the patient off the bed yourself.

Keep the bed free of crumbs and dirt that can rub and irritate the skin. Wash gently, avoiding rubbing or scrubbing the skin.

Use sheepskin boots and elbow pads to reduce friction on heels and elbows.

Avoid using irritating antiseptics, hydrogen peroxide, povidone iodine solution, or other harsh chemicals to clean or disinfect the skin. Betadine can be diluted with sugar (1 part Betadine to 4 parts sugar) and applied to dry wounds.

Avoid massaging the skin over bony areas. Avoid doughnut-shaped cushions. They can cut off circulation. 

Use pillows or wedges to keep the ankles and knees from touching each other.

Do not raise the head of the bed more than 30 degrees, unless your doctor instructs you otherwise. Raising the bed more than 30 degrees may cause the patient to slip off the bed, rupturing small blood vessels. Keep the skin clean and dry.

Clean the skin with saline rather than with soaps. As necessary, use absorbent pads to draw moisture away from vulnerable areas.

Never place pillows under the knees. This cuts off circulation.

Try to exercise. Even bedridden patients often can stretch and do isometric exercises. Exercise increases circulation. But to prevent diabetic foot ulcers, make sure that shoes fit properly and feet don't slip.

The principles of preventing decubitus ulcers in persons who are bound to a wheelchair are essentially the same as those for preventing bedsores. The critical difference in preventing bedsores, however, may lie in making sure that people who are confined to bed, or mostly confined to bed, are inspected from head to toe daily. If you are taking care of a family member, you may not want to be the one who does that. Having someone take care of bathing responsibilities, however, may do more than keeping your loved one clean. 

Image credits (both images): Dr. Andreas Settje, used with permission.

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