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Pressure sores: how we heal them in elderly and bedbound patients
Quick answer: Pressure sores (bed sores) are treated by assessing the wound and the whole patient, cleaning the wound and its pockets, and using VAC therapy until the cavity fills. The wound is then closed with a small local rotation flap, often under local infiltration anaesthesia rather than a general anaesthetic. Skin grafts are avoided because they are not stable over pressure areas. Turning, the right mattress and skin care prevent new sores.
A pressure sore is often the most worrying wound for a family caring for an elderly or bedbound relative. Here I explain how we assess these wounds, why I prefer a small local flap to close them, and what families can do to prevent them.
| Also called | Bed sore, pressure ulcer, decubitus ulcer |
|---|---|
| Who gets them | Elderly, bedbound or paralysed patients, especially with diabetes or poor nutrition |
| How the wound is assessed | The 4D approach: Dimensions, Developmental staging, Dermal assessment, Detection of contamination |
| General checks | Haemoglobin, protein levels, diabetes and other illnesses |
| Main treatment | Curettage of the wound and pockets, VAC therapy until the cavity fills |
| To close the wound | A small local rotation flap; skin grafts and large muscle flaps are avoided |
| Anaesthesia | Often local infiltration, without a general anaesthetic |
How is a pressure sore assessed?
Every wound is assessed with the 4D approach, which gives a complete picture of the wound itself:
- Dimensions: size and depth, including any pocket under the skin
- Developmental staging: the state of the edge and the centre
- Dermal assessment: pliability, blood supply and irritation of the surrounding skin
- Detection of contamination: foreign material, fungal or bacterial infection
The general assessment of the patient matters just as much. Haemoglobin and protein levels are checked, because a wound cannot heal without enough blood and nutrition. Diabetes and other illnesses are brought under control at the same time.
How are pressure sores treated?
- Curettage cleans the wound and the pocket beneath it of unhealthy tissue.
- VAC therapy keeps the wound clean and helps the cavity fill with healthy tissue. It is usually changed every 48 hours at first, then every 4 days.
- Closure: once the cavity has filled and the wound is small, it is closed.
Why a local flap, not a skin graft?
I always prefer a small local rotation flap to close a pressure sore. A skin graft is thin and not stable over a pressure area, so it tends to break down again. I also avoid large flaps and muscle flaps, because they carry more risk for elderly patients. A small local flap gives durable cover with less strain on the patient, and it can often be done under local infiltration anaesthesia.
Case: healed in an 85-year-old high-risk patient
An 85-year-old man with paraplegia, diabetes, high blood pressure and a previous heart attack, on blood thinners, had a pressure sore over his left hip. After curettage and 6 weeks of VAC therapy, the wound was closed with a local rotation flap under infiltration anaesthesia, without a general anaesthetic. It healed within 4 weeks, without complications. See the full case with photos.
How can families prevent pressure sores?
I teach families and nurses to:
- Change position frequently, so no area carries pressure for long
- Use a water mattress to spread the pressure
- Protect bony areas with silicone pads
- Moisturise the skin to prevent dryness, while avoiding dampness from sweat or incontinence
- Support good nutrition, as protein and haemoglobin levels affect healing
Pressure sores: frequently asked questions
Can a pressure sore heal in an elderly patient?
Yes. With careful assessment, VAC therapy and a small local flap, pressure sores can heal even in very elderly, high-risk patients. Our 85-year-old patient healed within 4 weeks of his flap.
Does closing a pressure sore need a general anaesthetic?
Not always. A small local rotation flap can often be done under local infiltration anaesthesia, which is safer for patients with heart disease or other illnesses.
Why not use a skin graft?
A skin graft is not stable over a pressure area and tends to break down. A local flap brings thicker, more durable skin to cover the wound.
How long does treatment take?
It depends on the size and depth of the sore and the patient's general health. In our case, the cavity filled with 6 weeks of VAC, and the wound healed within 4 weeks of the flap.
What blood tests matter for healing?
Haemoglobin and protein levels are checked, because low levels slow healing. Diabetes and other illnesses also need to be controlled.
How can I prevent bed sores in a family member?
Change their position often, use a water mattress and silicone pads over bony areas, moisturise the skin while keeping it from staying damp, and support good nutrition.
Send a photo and a short description and our team will advise on the next step.
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This article gives general information and does not replace medical advice. Treatment decisions are made only after an in-person examination. In an emergency, go to the nearest emergency department.