Old age, malnutrition, and pressure sores: an ill-fated alliance

Wound healing is a complex, tightly regulated process, consisting of three distinct phases. In each phase of wound healing, energy and macronutrients are required. Moreover, animal studies have established a specific role for certain nutrients such as the amino acid arginine, the vitamins A, B, and C, and the elements selenium, manganese, zinc, and copper. Chronic wounds such as pressure ulcers have extensively been investigated as to the risk of development, prevention, and cure. Here, the combination of old age, malnutrition, and pressure ulcers is highly unfortunate. Energy and nutrients, such as proteins and vitamins B and C, being deficient at old age are needed in pressure ulcer healing. Malnutrition is associated with skin anergy and with immobility because of mental apathy and muscle wasting. Severe malnutrition, impaired oral intake, and the risk of pressure ulcer formation appear to be interrelated. Adequate nutrition may reverse the underfed state unless an underlying wasting disease was present and appeared to reduce the prevalence and incidence in cross-sectional and prospective observational studies. However, attempts to prevent pressure ulcers by nutritional intervention were divergent in outcome, reflecting the difficulties to meet the daily requirements in elderly persons and the lack of knowledge about true nutritional needs in wound healing. The consumption of a diet high in protein and energy may promote pressure ulcer healing. When considering nutritional support, oral supplementation should be weighted against tube feeding, as the associated morbidity of tube feeding, i.e., diarrhea, fecal incontinence, and restricted mobility being in themselves risk factors for pressure ulcers, might obscure the favorable effects of adequate nutrition. Despite the evidence in animal studies, none of the above-mentioned specific nutrients promoted the healing of pressure ulcers in humans. Therefore, the attention should be focused on early recognition of a depleted nutritional status and an adequate and supervised intake of energy (35 kcal/kg) and protein (1.5 g/kg) with provision of the recommended daily allowances of micronutrients and with correction of the nutrient deficiencies of old age.