bedsores and nutrition

الرحيم الرحمن الله بسم

DR. SAFAA HUSSEIN ALIL E C T U R E R O F G E R I AT R I C M E D I C I N E

A I N S H A M S U N I V E R S I T YC A I R O – E G Y P T

S E N I O R R E G I S T R A R O F G E R I AT R I C M E D I C I N EP R I N C E M A N S O U R M I L I TA RY H O S P I TA L

TA I F- K S A

Nutritional support in prevention and treatment of

pressure ulcers

Burden

Pressure ulcer, while gaining increased attention from health-care decision makers, remains a large problem.

Reported prevalence in the acute setting ranges between 10 and 20%, and incidence rates between 4 and 10%. The annual cost of treating pressure ulcer in the United Kingdom was estimated to be £1.4–2.1 billion in 2004, equivalent to approximately 4% of the total NHS budget, and in the United States for the same time period it was estimated to be US$2.2–3.6 billion.

A large part of the cost attributable to pressure ulcer is the prolonged length of stay in the hospital to treat them. The economic opportunity cost of prolonged hospital stay is that beds are not available for use to other patients.

This amount included reimbursement for professional and support staff, wound care supplies, electrical stimulation, rental of equipment, and loss of potential income.

BURDEN OF ILLNESS

The impact of pressure ulcers can be seen in human and economic terms.

In human terms, the geriatric patient who develops a pressure ulcer has a four-fold increased risk of death. Pressure ulcers also affect quality of life and lead to more frequent hospitalization.

In economic terms, the cost of healing a pressure ulcer is likely high because it often involves a multitude of prolonged complex treatments and hospitalization. Once a pressure ulcer reaches stage III or IV, it may take as long as 6 months to heal. Experts advise that some ulcers may not be healable because of existing comorbidities and may require ongoing treatment and care.

Factors Influencing Healing

Many variables that can affect ulcer healing, including patient demographics, pressure ulcer size and severity, and pressure ulcer management practices.

NUTRITION AND SORES

TWO PARTS:DOES NUTRITION AFFECT BED SORE

HEALING?DOES NUTRITION HAVE A ROLE IN

PREVENTION OF BED SORES?

NUTRITION AND SORES

Previous findings indicate malnutrition is significantly associated with having pressure ulcer and the mean economic cost of pressure ulcer attributable to malnutrition .

Nutrition interventions have been found to reduce the incidence of pressure ulcer in patients at risk of developing pressure ulcer.

Meta-analysis of intensive nutrition support in the prevention of pressure ulcers (5 randomized controlled trials (RCTs), n=1325 patients) revealed a significantly lower incidence of pressure ulcer development in at-risk patients compared with standard care .

NUTRITION AND SORES

The economic modeling undertaken for this study predicts that a substantial number of cases of pressure ulcer could have been avoided, had an intensive nutrition support intervention been provided to all at-risk patients.

This corresponds to a substantial number of patient bed days that could have been used for purposes other than patients staying in hospital for an extended period of time with pressure ulcers. Importantly, there were no predicted additional cases of pressure ulcer or bed days lost to pressure ulcer from this model, with the minimum number of cases and bed days saved being 1082 and 3807, respectively .

NUTRITION AND SORES

Importantly, the model chosen predicted a 95.1% chance of being economically cost saving, while reducing the incidence of pressure ulcers and releasing valuable bed days for use by other patients. Of course, evaluation of the implementation of such an intervention is required to test whether the economic outcomes predicted are accurate.

An Evidence-Based Analysis

Supplementation with 15 grams of hydrolyzed protein 3 times daily did not affect complete healing but resulted in a 2-fold improvement in Pressure Ulcer Scale for Healing (PUSH) score compared with placebo.

Supplementation with 200 mg of zinc three times per day did not have any significant impact on the healing of pressure ulcers compared with a placebo.

Supplementation of 500 mg ascorbic acid twice daily was associated with a significantly greater decrease in the size of the ulcer compared with a placebo but did not have any significant impact on healing when compared with supplementation of 10 mg ascorbic acid three times daily.

A very high protein tube feeding (25% of energy as protein) resulted in a greater reduction in ulcer area in institutionalized tube-fed patients compared with a high protein tube feeding (16% of energy as protein).

Multinutrient supplements that contain zinc, arginine, and vitamin C were associated with a greater reduction in the area of the ulcers compared with standard hospital diet or to a standard supplement without zinc, arginine, or vitamin C.

Ont Health Technol Assess Ser. 2009; 9(3): 1–203.

Comparison of Protein Supplements and Placebo*

In an RCT, Lee et al. 2006 explored the effect of protein supplement on the healing of stage II, III, and IV pressure ulcers in long-term care residents. The trial compared 56 residents of long-term care facilities that received standard care plus a concentrated fortified collagen protein hydrolysate supplement for 8 weeks with 33 counterparts who received standard care and a placebo. Seventy-one of the subjects completed the study: 44 in the treatment group with 75 pressure ulcers and 27 in the placebo group with 33 pressure ulcers. At 8 weeks, the protein hydrolysate group showed twice the rate of pressure ulcer healing compared with the placebo group (mean improvement in PUSH score 5.56 for treatment vs. 2.85 for placebo). There were no significant differences among the groups in the rate of adverse events.

PROTEINS

Ek et al. 1991 studied the effect of a high protein, high calorie, vitamin and mineral-enriched liquid supplement on the development and healing of pressure ulcers. At the end of 26 weeks, 28 of the 67 (41.8%) pressure ulcers in the supplement group had healed compared with 25 of 83 (30.3%) pressure ulcers in the group that only received a standard diet. Although the nutritional supplement group had a higher incidence of healed ulcers compared with the control group (RR 1.39), this difference did not reach statistical significance (95% CI, 0.90–2.14, P = .14)

PROTEINS

Chernoff et al. 1999 reported in an RCT that 4 out of 6 institutionalized tube-fed patients that received a very high protein (25% of energy) enteral tube feeding had healed ulcers whereas none of the patients receiving a standard high protein (16% of energy) formula had healing of their pressure ulcers.

The group receiving a very high protein formula also had a 73% reduction in the surface area of the pressure ulcers compared with a 42% reduction in the control group. The differences in the rate of healing and surface reduction of the pressure ulcers did not reach statistical significance.

An Evidence-Based AnalysisHealth Quality Ontario







Zinc Supplementation

Zinc is a trace mineral that is an integral part of many body tissues and enzymes. It plays an important part in the synthesis of deoxyribonucleic acid and ribonucleic acid that foster tissue growth and healing, as well as collagen synthesis.

Zinc deficiency is associated with hair loss, diarrhea, poor appetite, decrease in sense of taste and smell, and lesions in the skin and eye.

A study had shown that up to 88% of eating-dependent nursing home residents had dietary zinc intake below 50% of the recommended daily allowance. Hence dietary supplementation of zinc had been investigated as a treatment for pressure ulcers. (Posthauer 2005, Advances in Skin and Wound Care)

Randomized Controlled Trial Comparing Zinc Supplement With Placebo*

In a randomized, double-blind crossover study, Norris et al. randomized 14 patients with pressure ulcers to receive either 200 mg zinc sulphate or placebo 3 times daily placebo for 24 weeks. Volume of the ulcers was measured every 4 weeks and after 12 weeks the groups switched therapy. Only 3 patients completed the study. The mean net change in the volume of pressure ulcers was 10 mL (SD 9 mL) in the zinc sulphate treated group compared with a net change of 6.0 mL (SD 17.5 mL). The difference between the groups was not statistically significant .

Randomized Controlled Trial Comparing Zinc Supplement With Placebo*

Brewer et al. (1967) reported no significant difference in the rate of pressure ulcer healing in spinal cord injury patients treated with 220 mg of zinc sulphate 3 times daily for 2 to 3 months (1/6 with healed pressure ulcer) compared with patients receiving a placebo (2/7 patients healed).

zinc

Houston et al. 2001 compared the adverse effects of 26 older institutionalized patients that received 440 mg zinc sulphate daily for the treatment of pressure ulcers with 44 patients with pressure ulcers that received similar care without zinc sulphate supplementation. After 30 days of treatment, the beneficial effects of zinc sulphate on healing were not obvious.

The only significant difference in healing between the groups over the 30 days was greater improvement in ulcer volume in patients with stage III or IV ulcer (P < .05), but not in stage II.

ZINC

However, zinc sulphate supplementation was associated with a higher incidence of adverse events. The odds of an infection requiring antibiotic therapy were 7.8 times greater in patients receiving zinc sulphate (P < .009). In addition, subjects with zinc sulphate were 12.5 times more likely to experience nausea/vomiting than were comparison subjects receiving similar care without zinc sulphate (P < .02). Adverse effects could not be explained by the presence of diabetes mellitus or differences in energy intake. (Houston, Haggard et al., 2001, Journal of American Geriatric Society 49 : 1130)

Ascorbic Acid Supplementation

Ascorbic acid is the enolic form of vitamin C. In addition to its antioxidative effects, vitamin C also plays an important role in tissue repair and regeneration within the body. It acts as a cofactor for enzymes involved in the synthesis of connective tissues, in particular collagen, an important process in wound healing.

Vitamin C deficiency has been associated with risk of pressure ulcer .

Elderly subjects admitted for femoral bone fracture that developed pressure ulcers were found to have leukocyte vitamin C levels about 50% lower than those in similar patients that remained ulcer free (Selvaag 2002).

Ascorbic…….

Tayor et al. 1974 compared 10 surgical patients with an existing pressure ulcer who received 500 mg of ascorbic acid twice daily with 10 patients who received a placebo twice daily. Both groups received similar wound care. After 1 month, 6 of the patients in the ascorbic acid group had complete ulcer closure compared with 3 patients in the placebo group.

Ascorbic…….

This difference was not statistically significant; however, patients in the ascorbic acid group showed significantly greater reduction in the mean ulcer area compared with the placebo group (84% vs. 42.7%,P < .005).

Ascorbic …….

In a more recent RCT, ter Riet et al. 1995 compared 42 nursing home patients with a pressure ulcer (grade 2 or worse) that received 500 mg ascorbic acid twice daily with 45 residents that received 10 mg ascorbic acid twice daily. After 12 weeks, there were no significant differences in the rate of absolute or relative reduction in surface area or volume of the ulcers between the groups.






Multinutrient supplements that contain zinc, arginine, and vitamin C were associated with a greater reduction in the area of the ulcers compared with standard hospital diet or to a standard supplement without zinc, arginine, or vitamin C. Ont Health Technol Assess Ser. 2009; 9(3): 1–203.

Multinutrient Supplement

The use of multinutrient (mixed nutrient) liquid nutritional supplements is a common practice to provide additional protein, energy, vitamins, and minerals to people requiring additional nutrition support.

Multinutrient

Benati et al. 2001 reported on the results of 16 hospitalized patients with severe cognitive impairment that were randomized into 3 arms. The study compared the effect of a high protein, high calorie supplement enriched with arginine, zinc, and antioxidants (vitamins A, C, and E) with a group receiving a similar supplement without the enrichment and a control group receiving a standard hospital diet.

Multinutrient

Benati et al. reported that patients treated with the supplement enriched with arginine, zinc, and antioxidants seemed to have the lowest pressure sore status tool score (best healing) and more rapid improvement. No numerical data was provided, however, and the statistical significance cannot be assessed.

Multinutrient

The decrease in PUSH scores (improvement in pressure ulcer healing) was –6.8 for the arginine-zinc-vitamin C enrichment group compared with –2.0 for the standard supplement group and –1.7 for the hospital diet group. However, there is insufficient data to determine whether the differences in improvements among the groups are statistically significant.

Multinutrient

Desneves et al. 2005 conducted a similar study to explore the effect of a high protein, high energy supplement enriched with arginine, zinc, and vitamin C. This treatment was compared with treatment with the same high protein, high energy supplement without enrichment and to the standard hospital diet.

Multinutrient

At the end of 3 weeks, patients that received supplementary arginine, zinc, and vitamin C had significantly better PUSH scores (P < .05) and had approximately 2.5-fold greater improvement in PUSH score compared with the other 2 groups, even though there were no significant differences in the patients’ intake of protein and energy among the 3 groups.






Multinutrient supplements that contain zinc, arginine, and vitamin C were associated with a greater reduction in the area of the ulcers compared with standard hospital diet or to a standard supplement without zinc, arginine, or vitamin C. Ont Health Technol Assess Ser. 2009; 9(3): 1–203.

Summary Statements – Nutrition Therapy

Supplementation with 15 grams of hydrolyzed protein 3 times daily did not affect complete healing but resulted in a 2-fold improvement in PUSH score compared with a placebo.

Supplementation with 200 mg of zinc 3 times daily did not have any significant impact on the healing of pressure ulcers compared with a placebo.

Supplementation of 500 mg ascorbic acid twice daily was associated with a significantly greater decrease in the size of the ulcer compared with a placebo but did not have any significant impact on healing when compared with supplementation of 10 mg ascorbic acid 3 times daily.

Summary Statements – Nutrition Therapy


Multinutrient supplements that contained zinc, arginine, and vitamin C were associated with a greater reduction in the area of the ulcers compared with standard hospital diet or to a standard supplement without zinc, arginine, or vitamin C.

It should be noted, however, that firm conclusions cannot be drawn because of methodological flaws and the small sample size.

PRESSURE ULCER PREVENTION AND NUTRITION

There are 5 relevant RCTs comparing the effectiveness of nutritional supplementation in addition to the standard hospital diet compared with the standard hospital diet alone.


Five studies compared the effect of nutritional supplementation on the incidence of pressure ulcers with that of a standard hospital diet.

Nutritional supplementation ranged from 1070 to 6300 kJ/day (254 to 1,500 c/day). The follow-up study period ranged from 2 weeks to 6 months.


In one study by Hartgrink et al., the nutritional supplementation was delivered via nasogastric tube.

All studies used a different pressure ulcer classification system for the outcome measure

RESULLTS

reports the results of the meta-analysis of the studies comparing nutritional supplementation and a standard diet to a standard hospital diet alone.

There is an overall statistically significant RRR of 15% in the incidence of pressure ulcers in favour of nutritional supplementation to a standard hospital diet.

TAKE HOME MESSAGE

Supplementation of standard hospital diet with protein, ascorbic acid (500 mg twice daily), or multinutrient supplements was associated with a significantly greater or faster reduction in the size of pressure ulcers, but did not result in a significant increase in the proportion of healed pressure ulcers.

Grade of Evidence

There is very low quality evidence supporting an RRR of 15% in the incidence of pressure ulcers when nutritional supplementation is added to a standard hospital diet.

bedsores and nutrition

Health & Medicine

pressure ulcer size

burden pressure ulcer

pressure ulcer scale

ulcer healing

healing of pressure

t r i c

incidence of pressure

prevention of pressure