Scholars and medics have defined pressure injury as areas of localized injury either to the underlying tissue or the skin, mainly over the prominence due to the sole effect of pressure or a combination of pressure and shear. The global prevalence of pressure injury is estimated at 12.8% of the total population, along with an incident rate of 5.4 patients per 10,000 people examined daily, out of which 8.5% of these cases are hospital-acquired pressure injuries (Li et al., 2020). In the United States (US), about 2.5 million victims of pressure ulcers are recorded annually (Bauer et al., 2016), coupled with mortality rates of 2 to 6 times as much as those registered from other diseases and approximately 60 000 deaths (Borojeny et al., 2020). Moreover, pressure ulcers cost between $ 9.1 to $ 11.6 billion yearly (Agency for Healthcare and Research Quality [AHRQ], n.d.; Borojeny et al., 2020). The most prevalent form of pressure ulcers is stage two, affecting primarily older people aged 65 and above.
Certain conditions spearhead the occurrence of pressure ulcers in aging individuals. Pressure ulcers emerge due to risk factors, including advanced age (65 years and above), immobility, mental disability, inadequate nutrition, and incontinence (Ebi et al., 2019). As per the Center for Disease Control and Prevention (CDC), pressure ulcers among elderly persons are among the most outstanding health and safety issues for nurses and hospitals in the US, as cited by Sharp et al. (2019). The US’s fast-growing segment of the old-age population is the reason for focusing this study on pressure ulcers among its aging population to determine possible ways of reducing the prevalence of this disease to save the country plenty of funds incurred in its medication.
Demographic and economic shifts cause the growth of the aging human population, notwithstanding the change in skin complexion. At present, about 11.5% of the global population are aged 60 years and above, and this percentage is anticipated to upsurge to 22% by 2050 (Hahnel et al., 2017). In the US, the life expectancy of the aging population has remarkably increased due to improved medical treatment and better living standards. In particular, the average life expectancy is between 70 and 82 years (Jaul et al., 2018). The increasing potential to live longer comes with the disease burden, and pressure injury is among the contributors to such burden.
As people age, many become frail, and it is the main reason for considering their safety. Aging pressure injury patients are linked to chronic diseases, malnutrition, dysplasia, and incontinence, which causes poor prognosis of pressure ulcers. If the condition is associated with septicaemia or infection, such contribute to more than 50% of deaths (Carryer et al., 2017). Its harmful effects include prolonged healing, pain, discomfort, recurrent hospitalizations and surgeries, and home care needs. Reasoning from a cost perspective, pressure injuries are part of the top five socioeconomic burdens in the US and can cost between $ 20,900-$ 151 700 per pressure ulcers patient (AHRQ, n.d.). Pressure ulcers among older adults remain a problematic nursing issue, particularly for those suffering from frailty and chronic diseases, making preventive measures awareness required.
Aging is a condition characterized by increased chances of visiting and spending in hospitals are high. Elderly persons become more vulnerable to chronic diseases, making them visit and spend in hospitals frequently (Jaul et al., 2018). Consequently, many older adults in the US reside in nursing homes, making them susceptible to developing pressure injuries. Exploring the prevalence of fundamental health issues among the aging human population is crucial to ensure continued quality in nursing (Cai et al., 2019). Studying such prevalence assists one to identify critical trends, required workforce capacity to deal with the issue, and workforce skills enhancement.
The study involved a three-step search strategy to find unpublished and public articles on pressure ulcers. In the first step, the researcher conducted an initial search via the Medline Ovid database to identify keywords associated with the study topic. In so doing, the reviewer minimized the risk of executing a biased search, as recommended by Wung Buh et al. (2021). In the Second Stage, the investigator used the identified keywords to search for studies in scholarly databases. Lastly, reference databases such as Cite Fast, Google Scholar were used to obtain references in the required format style.
In this research, PubMed, Google Scholar, Embase, Web of Science, Google, and Scopus were searched to gather relevant articles. The search was tailored to systematic search protocol executed using search terms pressure injury, pressure ulcers, and a combination of the two terms, namely pressure ulcers and injuries, as suggested in a similar study conducted by Borojeny et al. (2020) and Li et al. (2020). A search conducted in Google appeared resourceful because it yielded 23,300 million results in 3 seconds, but only a few articles, about 101, were relevant. Coincidentally, articles identified by Google-supported search were products of Web of Science, PubMed, Google Scholar, Embase, and Scopus. The investigation was mainly concentrated on establishing incidences of pressure ulcers among the aging population. The following criteria were used to exclude articles after the search, non-English published, duplicate, peer-reviewed, and outdated, published more than five years from the time of the study, yielding a total of 112 articles eventually.
Level of Evidence
Only the articles that met the inclusion criteria were considered for the study to achieve a high level of evidence. The Covalence software was used to screen the articles’ title, abstract, and full text. Two researchers were then employed to screen articles based on the titles to determine their eligibility. Any disagreement that arose from the two reviewers was resolved through open discussion by the third party, as Li et al. (2020) claimed. The process was repeated for the abstract and the full text to eliminate the non -required materials.
The reviewer attained the validity of the articles by employing two independent reviewers to assess the study’s methodology. The methodological validity of the articles was selected for retrieval before being eliminated by the inclusion criteria using the standard critical appraisal tools established by Joanna Briggs Institute for Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MASTARI) (Buh et al., 2021). Any conflict that erupted in the review was settled through discussing with peers. The methodological process adopted was in line with the condensed form of PRISMA, as in Li et al. (2020), and customized to three sets of criteria, namely title, abstract, and content of that articles.
After screening and selecting the articles, the information was loaded into an excel sheet for post-analysis. The data extraction tool adopted by the standardized JBI-MASTARI) was employed. For data synthesis, JBIMASRI, a specific tool for synthesizing quantitative research data was used. The tool was tailored to extracted information from the study articles such as characteristics, method of the study, participant characteristics, prevention strategies used, and the study outcome. By undertaking the procedures mentioned above of examining articles for inclusion, the review became satiated to have established a solution to the study problem.
Studies have addressed the need for new technology for preventing hospital-acquired pressure ulcers, particularly wearable patient sensors. Pickham et al. (2018) conducted a study on the effects of the wearable sensor for preventing pressure ulcers in adults. This study was based on two intensive care units (ICUs) in California’s Academic Medical Center. Research subjects in this study were adults admitted to the ICU between 2015 and 2016. Patients were subjected to either turning care relying on conventional turn reminders or optimal turning activities affected by the real-time wearable patient sensor. As a result of such intervention, a few hospital-based pressure injuries occur when a patient uses a wearable patient sensor.
Some scholars have discovered that nurse-based inappropriate nurse intervention is the cause of hospital-acquired pressure injuries. An example is an investigation done by Bliss et al. (2017), which sought to establish the incidence as well as prognosticators of incontinence-associated dermatitis (IAD) among occupants of nursing homes. This study used a cohort of 10,713 aged population (65 years and above). Specifically, the research focused on 44 nursing homes in 28 states within the US. The reviewer considered participants’ features such as features of occupants, the community that surrounds nursing homes, and nursing homes’ care environment. Subjects were exposed to a unique set of prevention and pressure injury orders from different nurse practitioners. It was established that patients never received IAD preventive interventions, leading to perineal pressure ulcers characterized by functional limitations, cognitive deficits, and more perfusion challenges.
Other studies have increasingly concentrated on the comorbidities associated with pressure ulcers in the aging population. For example, Jaul et al. (2018) investigated a summary of pressure ulcers development and comorbidities in older adults. This study aimed to describe acute and chronic conditions considered risk factors in the aging population for developing pressure injuries. The research presented an overall view of comorbidities associated with pressure ulcers in three-assorted patient geographical areas, explicitly the US, the UK, and other western countries, which encompass complication and multiple chronic diseases.
Frequent incidences of skin conditions in old-age people have also become a crucial issue for scholars. Hahnel et al. (2017) conducted a literature review on the epidemiology of skin conditions among older people, a study that integrated literature based on different countries, including the US. In so doing, the researchers searched databases such as Medline Ovid, PubMed, Web Science, Scopus, and Embase. The inclusion and exclusion criteria were employed to gauge the credibility and relevancy of articles. The researcher screened 1491 articles, which yielded 74 relevant papers for review. Eventually, the investigator depicted long-term care as the mainstream factor surging the prevalence of pressure injuries in elderly persons, and such prevalence varies within the range of 0.8-34% in different countries.
Preventions measures are essential for safeguarding the health of elderly persons irrespective of whether they are conventional or advanced. Wung Buh et al. (2021) inspected the impacts of implementing prevention measures for pressure ulcers among the aging population, as noted in Pressure Ulcer Prevention Practice Guidelines (PUPPG). This research involved systematic literature based on databases such as Cumulative Index to Nursing and Allied Health Literature (CINAH), Scopus, Cochrane Library, Medline Ovid, Embase, Web Science, and PubMed. Articles selected for this review mainly addressed the strategies used in the US and Canada. However, this study failed to include outcomes and conclusions. From this study, strategies used in preventing pressures ulcers are those suggested by PUPPG.
Scholars have put forward myriads of mitigation measures to curb the increasing prevalence of pressure injuries. One of the mitigation measures overwhelmingly discussed in the reviewed literature is the provision of sufficient nutrition to elderly persons, whether they are in hospitals, nursing homes, or their homes. Nurses and caregivers have paid little attention to what aging people eat, drink or chew. Whereas the AHRQ pressure ulcers prevention guidance recommends 3.5 gm/dl of serum albumin daily for aging individuals to reduce the risk of developing pressure ulcers, a study by Jaul et al. (2018) indicated that protein consumption is a more manageable vindication measure. Generally, aging individuals need a balanced diet to stop the unprecedented prevalence of pressure injuries among them.
Managing pressure ulcers can be more successful if all stakeholders play a collective responsibility. This involves nurses, nurse educators, families, and patients knowing what is expected of them. Bliss et al. (2017) stated that experienced nurses should provide expert interventions and educate junior staff members to improve patient outcomes. Additionally, nurses should implement care programs to improve the functional status of aging persons, provide assistance with skincare and incontinence, and treat perfusion problems (Bliss et al., 2019; Hahnel et al., 2017). Collective responsibility brings a sense of evidenced-based care, which means quality, affordable, increased accessible care.
The increased prevalence of pressure ulcers among elderly persons in the US is a severe nursing issue. This study is based on a systematic literature review to prove beyond reasonable doubt that pressure injury is a public health challenge among the aging population and to explore measures of curbing its increased prevalence. Pressure ulcers are associated with risk factors, including unusual skin changes, tissue inflammation, and the production of pus-like materials from body tissues. From the literature reviewed, pressure injury among older age people can be solved by implementing collective responsibility and providing a sufficient diet rich in protein (Jaul et al., 2018). Physical impacts of some forms of pressure ulcers are invisible, but it has caused the US a great deal of money in terms of footing medical bills of pressure ulcers patients.
Pressure injuries prevalence, to a larger extent, depends on the healthcare system. A study conducted by National Pressure Ulcer Advisory Panel (NPUAP) showed that pressure ulcers prevalence in hospitals varies from 0.4 % to 38 %, in specialized nursing institutions from 2.2- 23.9%, and in-home care providers from 0-17% (Hahnel et al., 2017). The bulk of pressure ulcers appear early in the admissions process. They can happen within the first two weeks for hospitalized patients. New evidence suggests that 15% of older patients can acquire pressure ulcers in the initial week of admission, owing to the increasing sensitivity of admitting elderly patients. By extension, pressure ulcers are most likely to occur in senior people admitted to lengthy care facilities during the first four weeks of their stay.
Pressure ulcers have also been linked to causing death in the aging human population. Numerous studies have found that older people with pressure ulcers died as high as 60% in a year of being discharged from the hospital (Bauer et al., 2016). Time and again, pressure ulcers do not cause direct deaths, instead, deaths occur due to a gradual deterioration in health. As such, pressure ulcers incidence can be used to anticipate mortality. According to the reviewed literature, repeated surgeries following diagnosis, pressure ulcers can severely damage the skin of aging persons.
Agency for Healthcare and Research Quality. (n.d.). Preventing Pressure Ulcers in Hospitals: Are we ready for this change? Web.
Bauer, K., Rock, K., Nazzal, M., Jones, O., & Qu, W. (2016). Pressure Ulcers in the United States’ Inpatient Population From 2008 to 2012: Results of a Retrospective Nationwide Study. Ostomy or wound management, 62(11), 30-38.
Bliss, D. Z., Mathiason, M. A., Gurvich, O., Savik, K., Eberly, L. E., Fisher, J., Wiltzen, K. R., Akermark, H., Hildebrandt, A., Jacobson, M., Funk, T., Beckman, A., & Larson, R. (2017). Incidence and predictors of incontinence-associated skin damage in nursing home residents with new-onset incontinence. Journal of Wound, Ostomy & Continence Nursing, 44(2), 165-171. Web.
Borojeny, L. A., Albatineh, A. N., Dehkordi, A. H., & Gheshlagh, R. G. (2020). The incidence of pressure ulcers and its associations in different wards of the hospital: A systematic review and meta-analysis. International Journal of Preventive Medicine, 11. Web.
Cai, J., Zha, M., Yuan, B., Xie, Q., & Chen, H. (2019). Prevalence of pressure injury among Chinese community‐dwelling older people and its risk factors: A national survey based on Chinese longitudinal healthy longevity survey. Journal of Advanced Nursing, 75(11), 2516-2525. Web.
Carryer, J., Weststrate, J., Yeung, P., Rodgers, V., Towers, A., & Jones, M. (2017). Prevalence of key care indicators of pressure injuries, incontinence, malnutrition, and falls among older adults living in nursing homes in New Zealand. Research in Nursing & Health, 40(6), 555-563. Web.
Ebi, W. E., Hirko, G. F., & Mijena, D. A. (2019). Nurses’ knowledge to pressure ulcer prevention in public hospitals in Wollega: A cross-sectional study design. BMC Nursing, 18(1). Web.
Hahnel, E., Lichterfeld, A., Blume-Peytavi, U., & Kottner, J. (2017). The epidemiology of skin conditions in the aged: A systematic review. Journal of Tissue Viability, 26(1), 20-28. Web.
Jaul, E., Barron, J., Rosenzweig, J. P., & Menczel, J. (2018). An overview of comorbidities and the development of pressure ulcers among older adults. BMC Geriatrics, 18(1). Web.
Li, Z., Lin, F., Thalib, L., & Chaboyer, W. (2020). Global prevalence and incidence of pressure injuries in hospitalised adult patients: A systematic review and meta-analysis. International Journal of Nursing Studies, 105, 103546. Web.
Pickham, D., Berte, N., Pihulic, M., Valdez, A., Mayer, B., & Desai, M. (2018). Effect of a wearable patient sensor on care delivery for preventing pressure injuries in acutely ill adults: A pragmatic randomized clinical trial (LS-HAPI study). International Journal of Nursing Studies, 80, 12-19. Web.
Sharp, C. A., Schulz Moore, J. S., & McLaws, M. (2019). Two-hourly repositioning for prevention of pressure ulcers in the elderly: Patient safety or elder abuse? Journal of Bioethical Inquiry, 16(1), 17-34. Web.
Wung Buh, A., Mahmoud, H., Chen, W., McInnes, M. D., & Fergusson, D. A. (2021). Effects of implementing pressure ulcer prevention practice guidelines (PUPPG) in the prevention of pressure ulcers among hospitalized elderly patients: A systematic review protocol. BMJ Open, 11(3), e043042. Web.