The relationship between malnutrition parameters and pressure ulcers in hospitals and nursing homes

Abstract

Objectives

Pressure ulcers (PU) remain a major health care problem throughout the world. Although malnutrition is considered to be one of the intrinsic risk factors for PU, more evidence is needed to identify the exact relation between PU and malnutrition. This study aims to identify whether there exists a relationship between PU and malnutrition in hospitals and nursing homes.

Methods

A cross-sectional study was performed in April 2007 in hospitals and nursing homes in Germany. PU were assessed using the Braden scale. Malnutrition was assessed by low body mass index (BMI), undesired weight loss, and insufficient nutritional intake.

Results

Two thousand three hundred ninety-three patients from 29 nursing homes and 4067 patients from 22 hospitals participated in the study. PU in both hospital and nursing home patients were significantly (P < 0.01) related to undesired weight loss (5%–10%). Moreover low nutritional intake and low BMI (<18.5) were also significantly related to PU in hospitals and nursing homes.

Conclusion

There is a significant relationship between malnutrition parameters like undesired weight loss, BMI < 18.5, and low nutritional intake and PU.

Introduction

Pressure ulcers (PU) have been described as one of the most costly and physically debilitating complications in the 20th century [1]. PU cause a great deal of discomfort for patients and increase the workload in all health care sectors; PU slow the rehabilitation process, delay hospital discharge, and furthermore increase costs considerably [2], [3]. PU is an area of localized damage to the skin and underlying tissue caused by pressure or shear and/or a combination of these [4], [5].

Whether a patient develops PU depends on both extrinsic and intrinsic factors. Important extrinsic factors (from outside the patient) that play a role in causing pressure sores are pressure, friction, and shear forces. These factors lead to mechanical loading at the skin level and secondary to skin damage and soft-tissue breakdown [6]. Intrinsic (patient-bound) factors affect tissue viability in the patient and by this the pathophysiologic response to mechanical loading. Several studies using logistic regression analysis indicate that the following intrinsic factors are significantly associated with the presence of PU: age, sex, limitation in activity, the need for assistance with the activities of daily living, bowel and/or bladder incontinence, total Braden Scale score, anemia, infection, and nutritional status [7], [8], [9], [10]. Nutritional status is one of the intrinsic factors that can be readily influenced. Both poor nutritional intake and poor nutritional status have been shown to correlate with the development of PU as well as with protracted healing of wounds [11], [12]. Notwithstanding methodologic shortcomings, cross-sectional and prospective studies also suggest that there is a fairly strong correlation between malnutrition (low body weight, poor oral food intake, and undesired weigh loss) and the development of PU [10], [11], [13], [14], [15], [16], [17], [18], [19], [20]. Malnutrition is a status of nutrition in which a deficiency (which is also called undernourishment) or excess, or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue, body structure, body function, and clinical outcome. In this article we mean by malnutrition a status of undernutrition.

A 2003 Cochrane review indicated that there is no strong scientific evidence for a direct relationship between poor nutrition and PU development and healing, although the methodologic quality of the studies that were included was weak [21]. Nevertheless, individual studies have demonstrated that an adequate nutritional intake may help to protect against PU development and improve the rate of PU healing [22], [23], [24], [25], [26], [27], [28], [29], [30]. A meta-analysis by Stratton et al. pointed out that, in four randomized controlled trials (RCTs), oral nutritional supplements (250–500 Kcal for 2 to 26 wk) were associated with a significantly lower incidence (25%) of PU development in “at-risk” patients compared with routine care. Furthermore, some studies showed a trend toward improved healing with high protein nutritional supplements when compared with studies using standard formulae. However, Stratton et al. indicated that more robust RCT studies are needed to scientifically confirm the latter finding [31].

The exact causal relationship between PU and (mal)nutrition still remains unclear. Uncertainty also surrounds the precise role of various macronutrients and micronutrients in the prevention and healing of PU [17], [18]. Because more evidence is needed as to whether there exists a relationship between PU and malnutrition, this study aims to investigate the relationship between malnutrition parameters and PU in patients admitted to German hospitals and nursing homes on a large scale.