RISK FACTORS FOR PRESSURE ULCER DEVELOPMENT IN INSTITUTIONALIZED ELDERLY

La finalidad del estudio fue analizar los factores de riesgo para el desarrollo de Ulceras por Presión (UP) en ancianos que viven en asilos. Es un estudio de cohorte prospectivo y fue desarrollado en cuatro instituciones. Noventa cuatro ancianos compusieron la muestra y fueron evaluados consecutivamente hasta tres meses. Las puntuaciones totales de la Escala de Braden fueron diferentes entre los grupos con y sin UP, en la primera (p=0.030) y la última evaluación (P = 0.001); humedad, nutrición y fricción fueron estadísticamente diferente entre los ancianos con y sin UP, peor entre aquellos con UP. El sexo femenino y UP previo fueron confirmados como predictivos para el desarrollo de PU (r2=0,311).


INTRODUCTION
Certain risk factors have been confirmed as predictive for pressure ulcer (PU) development, which implies physical, emotional, and social overloads for patients and their families.This consequently reduces the quality of life and increases health service costs, due to longer hospitalization periods and higher morbidity and mortality rates.
In relation to the PU concept, two definitions have been adopted: the National Pressure Ulcer Advisory Panel (NPUAP) (1) stated that "PU are caused by prolonged pressure and typically occur on bony prominences in individuals restrained to a bed or wheelchair"; and the European Pressure Ulcer Advisory Panel (EPUAP) (2) says that "PU is an area of cellular death on the skin and underlying tissues caused by pressure, shearing, friction and or a combination of these factors".These concepts establish not only the nomenclature currently employed for this type of lesion, but also its main etiology.
In 1987, North American authors (3)  Pseudo-senescence, on the other hand, results from the aggression of environmental factors on the human skin throughout one's existence (4) .
Elderly skin assessment is based on physiological criteria like hydration, changes in sebaceous secretion and sweat glands and permeability; and biological criteria, based on changes to the connective tissue and the four intercellular matrix molecules: collagen, elastin, proteoglycans and glycoprotein, as well as the fibroblasts that synthesize them (4) .
Aging fragileness associated with morbid conditions, such as changes to neurological and mental states, nutritional conditions, mobility, anal and urinary activity and continence, characterizes a population predisposed to PU development, reoccurrence and complications.This is an overall view that has led to the growing need for their institutionalization (5) .
Long-Stay Institutions for the Elderly (LSIE) are facilities designed for integral institutional care.
The target population includes people older than 60, dependent or not, who are not able to stay with their family or at home.These institutions receive various names, including: shelter, home, nursing home and geriatric clinic.To meet this age group's needs, these facilities provide, for instance, social, medical, psychological, nursing, physical therapy, occupational therapy and dental services (6) .
These locations should provide a residential environment, keeping the characteristics of a home.
They should not be marked by isolation, away from urban life, or be a space that simplifies its users' lives (6) . The

CASUISTIC AND METHOD
This quantitative prospective cohort study After receiving agreement, written consent was requested.In case the participant was not physically or mentally capable of providing written consent, requests were made to those responsible at the institution.
After obtaining consent from the elderly or the person responsible and after checking their ages, the next step was to assess UP development risk, using the Braden Scale and physical examination, aiming to detect previous PU.Elderly with risk scores ≤ 18 (8) were included in the study sample until PU

Some clinical variables, such as Body Mass
Index (BMI) and PU stages, were evaluated according to international standards (1) .PU measurement was done with a millimeter ruler: the length was measured in the cephalic-caudal direction, and width in the latero-lateral direction.For ulcers in stages II and IV, depths were evaluated using sterilized cotton swabs, which were later measured with the standardized millimeter rule.Irregular wounds were measured by the largest dimensions, as per international recommendations (9) .
Results were subjected to the following tests: Pearson's chi-square, Fischer's exact, Kolmogorov- Braden Scale -final assessment

DISCUSSION
LSIE showed difficulties regarding elderly health maintenance, especially because they often presented organic system impairment, including the skin, due to the natural aging process, associated with chronic-degenerative diseases that cause various changes, making elderly weaker and more vulnerable (5) .
In addition, other changes, such as dementia, neuro-motor and muscular-skeletal impairments, also common among the elderly and often the cause of their institutionalization, limit their lifestyle, self care and activities.Therefore, this certainly affects their sensorial perception, mobility, activity, nutrition and moisture, as clinical factors of PU risk (3) .
Anal and urinary incontinence are former clinical situations that require specific approaches due to the involved prejudice, myths and taboos, which  Clinically, LSIE elderly were within normal nutritional standards, with none to six illnesses each, mostly urinary, cardiovascular and respiratory.The most frequent drugs used were neuroleptics and psychotropics.These conditions, associated with previous PU, which is the case of approximately one third of the elderly, in addition to mobility impairment -as the most important risk on both the first and final assessments -caused higher vulnerability to developing these lesions.Another study previously described the use of sedatives as a risk factor for PU development, since patients do not feel the need to change positions, thus compromising the mobility/ activity factor (10) .
In this sense, during data collection, it was observed that the elderly developed few activities.
They ate and slept, few performed occupational therapy and, despite being encouraged, they reported tiredness and lack of vitality.This led to a need for long rest periods, which affected activity and mobility levels.
Despite the prevalence of urinary diseases, as a general characteristic for the 94 studied elderly, there was no difference between the groups with and without PU.Nevertheless, moisture -being very wet -showed a statistically significant association with the presence of PU on both the first and final assessments.
Excessive moisture, especially due to urinary incontinence, also relates with friction and shearing (11)   , which are common among elderly with PU, as a real or potential problem on the final assessment.
Anal and urinary incontinence are clinical situations that require specific approaches, since the resulting permanent moisture often turns these situations into the main reason for these people's institutionalization.
Though most elderly have a normal BMI, their food consumption -evaluated by the Braden nutrition subscale -was compromised.Very poor or inadequate nutrition was present in 51.3% of elderly with PU, which was significantly different from the group without PU.LSIE frequently report difficulties regarding independence to eat.A study that assessed the influence of BMI on the gluteal-ischiatic interface pressure in a population of institutionalized elderly (12) evidenced that pressure on this region was higher in thin elders with low BMI.Despite our findings, another study (13) showed that every sub-scale, except nutrition, presented statistically significant associations that indicated the risk of ulceration.
Other authors (14) describe hypoalbuminemia, low diastolic pressure, anal and urinary incontinence and peripheral edema as factors that cause PU among elderly in rehabilitation units.Not all these factors were investigated in the present study.Nevertheless, the presence of these co-morbidities is an important epidemiological fact for further coping with these conditions.In the referred study, Braden sub-scales were classified as primary risk factors; and age, edema and hypotension were considered secondary factors for developing PU.Results for primary factors were similar to those of the present study, for the same sub-scales: moisture, nutrition, friction and shearing.
It was observed that women and previous PU are predictive of PU occurrence, compared to men and elderly without previous lesions.
Among the surveyed studies, despite the prevalence of women in most, PU incidence was higher among men, with no epidemiological foundations for both findings.As for previous PU, only one of the studies (15) reports the higher severity of elderly admitted with PU, indicating higher mortality.
The significant differences between total Braden Scale scores for elderly with and without PU, on the first and final assessments, always lower for the first group, confirm the importance of systematic risk assessment to implement early preventive measures.
In a study about this scale's predictive validity, the author (14) demonstrated that scores decreased in every sub-scale when subjects had PU.
In another longitudinal prospective study (16) about PU prevention methods in acute care hospital units, rehabilitation facilities and nursing homes, the authors showed that many PU prevention strategies Finally, it should be stated that risk assessment -based on knowledge concerning specific factors -in addition to early prevention and intervention are crucial for approaching the threatening prevalence and incidence of PU in this population.

FINAL CONSIDERATIONS
Population aging, including in our country, has caused a significant increase in the so-called LSIE.These facilities are an alternative residence for elderly and all of them admit that they should undergo significant changes in structure and human resources over the next decades.
Regarding the elderly, it is observed that this generation did not have access to information like today.Perhaps this causes a passive approval of aging, different from today's adults, who seem to struggle to stop time.It is most likely that the vast majority is already concerned with how they will live the senescence phase.Nursing should make more use of these technological alternatives in the educational process of families and patients.
By knowing and detecting the prevailing risk factors of PU development in institutionalized elderly, as well as their influence on sensorial perception, mobility, activity, moisture and friction and shearing, it is possible to elaborate and systemize prophylactic nursing and multidisciplinary measures.
Among the factors identified in this study, it should be recognized that mobility appeared to be one of the most important for the occurrence of PU.
The multiple causality of these lesions, however, also shows that changes in sensorial perception -also due to continuous medication use, such as neuroleptics/ psychotropics-as well as the identified illnesses, especially urinary -which compromise moisture and cause friction and shearing -confirm the characterization of a population that is highly vulnerable to developing these chronic lesions.
Elderly and caregivers, either professional or not, should be constantly instructed about the importance of and measures for pressure relief, reviewing and implementing simple procedures, such as changing decubitus, correctly using mobile sheets, sitting and lying positions, preventing movement friction, controlling moisture, as well as facilitating and encouraging eating and hydration; which is essential for the elderly, particularly when institutionalized.
was carried out at four LSIE in three cities in Southern Minas Gerais State, selected by their characteristics: philanthropic, non-profit organizations (recognized as of Federal Public Utility and registered under the National Social Service Council), with similar human and physical resources.The project was first approved by the Institutions' Administrative Councils, and next by the Institutional Review Board at the University Vale do Sapucai (UNIVAS), under protocol number 244/04, and according to resolution 196/96 by the National Health Council regarding research involving human beings.In this study, the LSIE are identified by letters -A, B, C, and D -so as to preserve ethic secrecy regarding their real names.At these institutions, health care is not systemized and there are no PU prevention protocols, including specific risk assessment for development or treatment.In fact, treatment is initiated when PU are detected, usually from stage II onwards.The study population consisted of 275 elderly, residents in LSIE during the data collection period; distributed as follows: A= 56; B= 71; C= 46; and D= 102 elderly.Ninety-four elderly comprised the study sample, and met the following criteria: aged 60 years or older; Braden Scale score indicating PU development risk; and agreement to participate in the study.The exclusion of 181 elderly from several institutions occurred due to: age under 60 years (36), total Braden score ≥ 19 (139), refusal to take part in the study (6).Moreover, three deaths occurred among the elderly in the final sample.The lead researcher and nine collaborators collected the data.Collaborators participated in a sixstage training program, consisting of theoretical and practical classes, in addition to group and individual assessments.They were considered apt for data collection when a 100% agreement was obtained among the simultaneous observations made by collaborators and the researcher.Folders with data collection instruments, lists with the resident elderly people's names and the program for visiting days were appropriately organized for each LSIE.
development, death, transfer, "discharge" or followup completion (90 days).Data collection took place in 2004, and was performed three times a week (Mondays, Wednesdays and Fridays); from June to September at institutions A and B, from August to November at institution C and from October to December at institution D. Elderly with previous PU who still had a risk score were kept in the study to evaluate the occurrence of new lesions.Elderly admitted to the LSIE before the 80 th data collection day, who met the inclusion criteria, were evaluated until completing at least 20 evaluation days.When participants were transferred from the LSIE to hospital or their home, they were considered new cases only if their return to LSIE occurred 3 days after they had left the institution.During follow-up, when PU was detected, a careful local exam was performed, evaluating stage, measurement and location.From this moment onwards, elderly were excluded from the study and lesion treatment was initiated, in accordance with the institution's practice.Sociodemographic and clinical data (diseases and drugs used) were collected from the institution's patient form and completed at their side, during the physical examination.Other data, like weight and height, were collected through individual evaluations, using standardized techniques and equipment in every LSIE.Techniques were adjusted to participants who were restricted to their beds.

Figure 1 -Figure 1
Figure 1 -Braden's sub-scale score rates, on the 1 st assessment

Figure 2 -
Figure 2 -Braden's sub-scale score rates, on the final assessment made diagnosis and treatment difficult.This led to permanent moisture and often turned these situations into the main reason for the elderly people's institutionalization.This array of impairments and fragileness imply specific health care needs.These needs require human or physical support that is often possible only through institutionalization.However, as opposed to what is expected, institutionalization can increase these clients' dependence and lack of autonomy.Since prevention is still the best medicine, this study aimed to investigate risk factors present in the institutionalized elderly.

Figure 3 -Figure 4 -Figure 5 -
Figure 3 -Elderly with and without PU, according to moisture subscale scores on the final assessment