What is a Pressure Ulcer (AKA Pressure sore)?

shutterstock_89421025bed-soresPhoto credit:  http://diseasespictures.com/bedsores/

A patient came in to see me today with a sore on his heel that’s been bothering him for the past few months.  He’s diabetic and has lost feeling in the bottom of his feet.  He’s had these pressure sores in the past but has trouble getting them to heal up.

Pressure sore:  Areas of skin that have been damaged by pressure such as sitting or lying in one position for a very long period of time.  They can also be called “bedsores.”  The are more commonly found in areas of the body where the bone is near the surface of the skin such as on the hips, elbows, ankles and back/buttocks. The skin and soft tissues become damaged because not enough oxygenated blood can get to the area to promote healing usually due to the compression of the damaged skin and soft against hard bone tissue.

Appearance:  The sores change in the way they look depending on how long they’ve been present and how much damage has been done.  In the beginning, the sore appears as a small red patch of skin, and if not treated, the skin will break down and cause a hole or crater to form (we call this an ulcer).

Stage 1:  The skin is intact without ulcers but when you push on the skin it does not change colors to indicate good blood flow.  Usually, healthy tissue will be pink and when you push on the area with your finger you can notice it will become less pink and in a couple seconds the pinkness will return.  This does not happen in the damaged skin at this stage – it may have a darkly pigmented color.

Stage 2:  There is an open, shallow ulcer with a red-pink color at the base of the wound.  Sometimes there may be blisters present which are either intact or ruptured.

Stage 3:  Structures beneath the skin such as fat may be exposed but at this stage, you should not see bone, tendons or muscle tissue.

Stage 4:  Structures beneath this skin including bone, tendon and muscle may be seen in the bottom part of the ulcer

People at Risk:  Some patients are more at risk than others of getting pressure sores.

1)   Patients who cannot move very well because they have a medical problem.  These people may sit or lay in one position for a long time.  They need help to move to a different position so that the skin doesn’t form sores.

2)   Older people are more prone to pressure sores because they often don’t move around as much and their skin is more fragile and thinner than a younger person.

3)   Patients who have diabetes or nerve problems in their feet may not feel when a small pebble or area gets into their shoe or pressure pushes on the foot causing injury.

4)   Patients in the hospital or nursing home are at especially high risk for many of the factors noted above – increased age, decreased mobility, and other complicated medical problems.

Prevention:  Some things can be done to lower the chances of getting pressure sores

1)   Repositioning the patient’s body every two hours so that they are not lying on one area where the skin is being crushed, pinched or pressure is building

2)   Putting pillows between the ankles and knees to decrease the pressure on the skin over these boney areas

3)   Raising the head of the bed when the patient is lying on their side to decrease the pressure on the hip bone

4)   Getting special foam or soft mattresses that decrease the pressure on the areas of the body that have the most pressure on them

For patients in wheelchairs:

1)   Use a special cushioned seat if possible to prevent pressure on the sacrum

2)   Every hour tilt forward or to the side to release pressure on the seat

3)   If ankles or heels press on the chair, use foam padding to protect against sores

4)   Check skin regularly for signs of pressure or ulcers

Treatment:  Pressure sores are treated differently depending on the stage of ulceration and how severe the damage to the skin is.

1)   If there is mild erythema, the treatment is generally off-loading the area but decreasing the amount of time that this area is compressed by body re-positioning, and/or using pillows to cushion the area.  We also use transparent films over the ulcers to protect the areas.

2)   In patients who have diabetes, adequately managing blood sugars to keep them under good control is very important.  Elevated blood sugars impede wound healing.

3)   If there is dead or dying skin or soft tissues, this often needs to be removed to help prevent infection.

4)   Special bandages may be needed to keep the healing tissue moist but prevent tissue maceration (from being too moist). Sometimes the dressings that we use to treat wounds can be very expensive.

5)   Antibiotics may be prescribed if there is a wound infection

6)   Medication for pain may also be prescribed

There are some tools to score the pressure and grade the healing process.  These are helpful for patients who come back for repeat visits to wound care clinic or their primary care provider and there is a need to grade the healing by giving them a score.  Some clinical features that are examined include:

1)   Amount of Exudate

2)   Skin color surrounding the wound

3)   Peripheral tissue swelling

4)   Peripheral tissue firmness around the wound

5)   Amount of granulation (healing) tissue

6)   How much epithilization is present

It’s important to optimize the nutritional status of patients with wounds.  Particularly for patients who have Stage 3 and 4 ulcers, they need enough protein and calories to help heal these wounds.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

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Diabetes Foot Care

shutterstock_110360354Patients who have diabetes need to pay extra attention to their foot care to help prevent infections.  I’ve had numerous patients with diabetes need foot or toe amputations that could have been prevented with excellent foot hygiene.  Small scrapes in the skin or ingrown nails can become extremely bad very quickly with diabetes because patients who have diabetes often don’t have as much sensation (due to damage to the nerve endings and blood vessels in your feet).  This can make it difficult to detect sores and once an infection is present it can be very difficult to treat.  I thought I’d put together some tips to help you keep your feet healthy and decrease the risk for infections.

1)      Stop smoking:  If you smoke, this can decrease the blood flowing to your feet and make foot problems worse.

2)     Inspect your feet everyday:  Look for blisters, cuts, cracks or sores.  If you cannot see your feet well then use a mirror or have a family member help you.

3)     Wash your feet everyday:  Use warm (not hot) water – be sure to check the temperature with your hands rather than your feet.

4)     Dry your feet well:  Pat them dry and do not rub the skin on your feet too hard.  Dry between each toe.  If the skin on your feet stays moist, bacteria or fungus can grow and that might lead to a foot infection.

5)     Keep your feet soft:  Use a skin moisturizer such as Aveeno, Dove or Cetaphil on your feet to keep your skin soft and prevent calluses and cracks.  Don’t put the cream between your toes unless you are treating athlete’s foot with a fungal cream.  Make sure to wear socks or traction on your feet after applying the cream so you don’t slip and fall.

6)     Clean under your toenails carefully:  Don’t use sharp objects under your toenails.  Instead use the blunt end of a nail file or other rounded tool to decrease the chance of piercing the skin.

7)     Trim and file your toenails straight across:  This helps prevent ingrown nails.  Use a nail clipper instead of scissors.  Then use an emery board to smooth the edges.  If you need help trimming your nails, schedule an appointment with your medical provider.

8)     Change your socks everyday:  Socks should have a thick cushion and fit loosely around your feet.  Socks without seams are best because seams often rub the feet.  Do not wear stockings, socks, or garters that come up to the thigh or knees unless your medical provider advises you to do so because they can decrease the blood flow to your feet.

9)     Look inside your shoes before putting them on:  Check them every day for gravel, torn linings, or thorns that can cause blisters or sores.

10)  Do not go barefoot:  Don’t wear sandals or shoes with thin soles because these types of shoes are easy to puncture.  They also do not protect your feet from hot pavement or cold weather.

11)  Have your medical provider check your feet during each visit:  If you notice a problem with your feet, see your medical provider right away rather than trying to treat it with a home remedy.  Some home remedies or treatments that you can buy without a prescription (such as corn removers) can be harmful.

12)  Keep your blood sugar down:  Watch what and how you eat, monitor your blood sugar, take your medications and get regular exercise.

When to seek medical help:

A)      If you cannot do proper foot care

B)     If you have a foot sore or ulcer that is not healing after 3 days (including corns, calluses or ingrown nails)

C)     If you have black and blue areas in your toes or feet

D)    If you have peeling skin or blisters between your toes

E)     If you have a fever for more than 24 hours and a foot sore

F)     If you have new numbness or tingling in your feet that does not go away after you move your feet or change positions

G)    If you have unexplained or unusual swelling of your foot or ankle

H)    Anytime you have questions about your feet or concerns it is best to contact your medical provider

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Testosterone Deficiency – aka “Low T”

shutterstock_148300076Low testosterone is a hot topic right now in primary care.  Recent advertisements are on television discussing various testosterone treatments available to men with “Low T.”  I’ve recently had quite a few patients asking me to check testosterone levels and then they usually have questions about testosterone treatments if the blood levels are abnormal.

Testosterone is a hormone that is produced in both men and women, but it is usually present at higher levels in men.  The consequences of low serum testosterone are not known for certain but there are several possible symptoms of low levels including (research is still being done):

  1. Low sex drive, erectile dysfunction, poor morning erection
  2. Fatigue
  3. Being slow to go through puberty (if it is too low during childhood)
  4. Decreased bone mineral density
  5. Decreased muscle mass
  6. Decreased muscle strength
  7. Anemia
  8. Decreased mood
  9. Decreased cognitive function

Of course there are other, more common causes of low sex drive and fatigue that can affect grown men instead of low testosterone levels.  Experts believe that the current trials have demonstrated weak and indirect inferences about the usefulness of testosterone for osteoporosis in men.

Testosterone levels naturally decrease as men age.  This normal decline in testosterone however has not had established clinical consequences.  We are still studying the effect that the natural decline of testosterone levels have in the body.  Elderly men often ask if they should be prescribed supplemental testosterone to keep their levels from decreasing.  The answer is difficult because we currently do not entirely understand whether the changes in body generally associated with aging (decreased muscle mass, decreased energy) may be related to naturally decreasing testosterone levels or even if treatment with testosterone reverses the decreasing muscle mass and energy we see in the average person with increasing age.  We’re also concerned about adverse consequences of testosterone with diseases that are testosterone dependent such as prostate cancer.

Controversy regarding testosterone whether to prescribe testosterone therapy:  A committee of the Institute of Medicine of the National Academy of Sciences Committee reviewed available studies and concluded that no beneficial effects of administering testosterone have been well established.  The Endocrine Society however has published evidence based guidelines for testosterone therapy in adult men with deficiency of testosterone.  The guidelines from the Endocrine society are:

  1. Testosterone therapy should be prescribed only for men with low serum testosterone levels on more than one test and who have symptoms of testosterone deficiency and have no known pituitary or testicular disease.
  2. In order to minimize the potential risk of causing testosterone-dependent diseases, the target level of testosterone level in the blood should be between 300-400 ng/dL (10.4 to 13.9 nmol/L)

The Institute of Medicine’s committee on testosterone concluded that there is insufficient evidence to conclude that testosterone treatment of elderly men has any well-established benefit thus far on improving muscle strength, physical function, vitality, sexual function, cognition and quality of life.  They recommended further investigation.

Potential to cause harm:  High testosterone levels has the potential to cause cancer of the prostate but data are limited.  The common practice in treating prostate cancer is to lower serum testosterone levels with medications.

Screening for low testosterone:  One approach has been the following:

  1. If a male has symptoms of possible testosterone deficiency such as decreased sex drive, energy, mood or osteoporosis or anemia a serum testosterone level can be checked early in the morning (before 8am when normal testosterone levels are highest).  If the level is low, it should be repeated for confirmation.
  2. Free testosterone levels should only be evaluated in men who have obesity.
  3. If testosterone levels (both times) is less than 200 ng/dL (6.9 nmol/L) evaluation for causes of hypogonadism can be performed. If there is no pituitary or testicular disease, discuss  with the patient about possible treatment with supplemental testosterone (ie. Benefits vs risks).

Testosterone treatment:  One approach to treatment has been the following:

  1. If treatment is started and the symptoms that led to measuring the testosterone are not corrected (improved energy, sex drive, anemia, etc.)  within a few months then discontinuing the testosterone treatment can be considered.
  2. Before starting treatment, a digital rectal exam should be performed and a PSA (prostate specific antigen) measured.  If a man has higher than normal PSA with no identifiable risk factors a urological evaluation should be performed before any testosterone therapy is started.
  3. 3 months after starting the testosterone treatment, a digital rectal exam and PSA should be repeated.  If there is a prostate nodule or the PSA has increased more than 1.4ng/mL (and confirmed) urological consult should be sought.  If the PSA and digital rectal exam is not considered abnormal, the digital rectal exam and PSA should be performed once a year  (just as with any man).

References:  Bhasin S, Cunningham GR, Hayes FJ, Matsumoto AM, Snyder PJ, Swerdloff RS, Montori VM, Task Force, Endocrine Society. Testosterone therapy in men with androgen deficiency syndromes: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010 Jun;95(6):2536-59.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Tips for Managing your Elderly Parent’s Medication

shutterstock_138204188Many of my clients caring for elderly parents struggle with the fact that their parent has a tough time remembering what medications they are taking and what the purpose is for each medication that they are prescribed. Many seniors are taking multiple medications, with doses sometimes several times throughout the day. The truth is that as we age our memory frequently declines, which can make it challenging to remember all of the details of our daily routines. However, it is critical that patients are taking the proper medications, because their health may be adversely affected.

I believe that helping our patients understand why they take certain medications keeps them involved in their own care and also helps them remember to take them, and typically provide the following recommendations to help patients remember to take their medications:

1. Give the patient an updated list of his/her medications each time they are seen by a medical provider and explain how to take them. In addition, briefly describe what the medication is used for. A short description such as “Blood Pressure” or “Cholesterol” is sufficient so that the patient is able to recall why they are taking it. Make sure this list is in large font and easy to read. Laminating the list makes it more durable. Patients should post this list on the refrigerator or in a location near their medications so that they have it for easy reference. Each time a change is made to one or more of the patient’s medications, a new list is made and given to the patient. If the change is done over the phone – the list should be mailed or emailed to the patient. I routinely give my patients a copy of their updated medication list on a USB device which is carried with them daily. If they go to another medical provider or hospital, they can easily access their updated medication list on their USB drive – it is also available to be stored “in the cloud” – i.e. on a secure website, if they prefer not to carry it with them.

2. Put medicine in a location of the home that your parent visits often. – Next to the coffee maker or water dispenser, or next to the sink in the bathroom are all good places and the bottles serve as visual reminders.

3. Review your parent’s medication bottles at each visit. If you visit the patient at their home or office, look at each bottle and make sure the medication is on the patient’s list and also in the patient’s chart. If this is done at each visit, errors can be avoided, especially if an old or outdated prescription is being used by the patient. At this time, new prescriptions can be issued before the patient runs out of the medication.

4. Pill Boxes and Dispensers are a simple and relatively affordable tool that has proven to work well as it allows you to plan dosage and also track consumption. Most pill boxes can be purchased at a pharmacy and are typically under $5. Some of the higher-end pill boxes also feature built in reminders.

5. Prescription bottle alarms or reminder devices are increasingly available, which can alert them that they are due to take their medicine. Some of these bottle caps glow, and/or give a sound alert reminder. They also have bottle caps which can send a text message to the patient’s phone or an email that can be a great reminder for the tech-savvy patient. One company that produces these prescription bottle caps is: Vitality – and they make GlowCaps. A simple alarm functionality on a cell phone or a calendar meeting reminder also works well.

Vitality GlowCaps from Vitality on Vimeo.

6. There are also a set of new Mobile Applications designed for the iPhone, iPad, and other mobile devices that  help you track and manage medications. A few of the noteworthy ones to check out are: iPills, PillboxPillboxer, and The Pill Phone.

Remembering to take medications appropriately can be challenging, but caregivers can help patients do this with simple tools and a little extra time.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Addressing Wishes for End of Life Care

shutterstock_57012596Last week, I was consulted by a patient who wished to discuss their wishes for end of life care, but did not know how to bring up the subject with their families and care takers. Because this can be a challenging and emotionally filled conversation, often family members are not aware of the wishes of their older loved one.

It is common medical practice to ask elderly or terminally ill patients about their wishes if they were to be taken to the hospital at a time of respiratory distress or cardiac arrest. For a younger patient there is no question that everything would be done, including insertion of an artificial airway to help them breath if needed, to give CPR including chest compressions as well as starting an IV to administer medications. An elderly patient near the end of their life may not wish to have all of these measures taken, and may even resent this treatment if it does not coincide with their wishes. Many patients are not aware that hospitals are required by law to undertake resusitation measures unless the patient has a specific order on file.

Talking with a loved one about difficult issues is not easy, but being proactive and listening to their wishes can save frustrations later and give the elderly loved one the peace of mind that their wishes have been heard. It is also easier for family members to accept these decisions and be the proper advocate for their family in times of crisis after this has been discussed in advance.

Many hospitals can provide their patients and their families with a worksheet that can help plan end of life care. If filled out in advance and posted in a convenient location such as the refrigerator, it can be easily accessed in an emergency at a time when ambulance staff arrives to take the patient to the hospital. State-specific advance directives can be downloaded on the National Hospice and Palliative Care Organization (NHPCO) Web site.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

How Physicians can Enable Longer Independent Living for Seniors

One of the primary goals of my practice is to help my elderly patients continue to live longer, healthier lives in their familiar surroundings and established communities.  Also, one of the most common questions I hear from the families that I care for is “How do I allow my loved one to keep their independence?”

Medical conditions that  can make living at home difficult include problems remembering to take medications, issues with mobility such as recent hip fractures, as well as complicated medical problems such as congestive heart failure, out of control diabetes and severe COPD.  Oftentimes the elderly patient’s family lives far away, even in another state so helping your elderly parent be sure that they are getting the proper care that they need also often challenging.

I believe that having a primary care provider who coordinates all of the medical care that your elderly family member needs is most important.  I find it extremely rewarding to help my patients navigate the often confusing healthcare system.

Several tools help me assist my patients at home:

1)  Prescription Bottle Caps which have a timer to help patients remember to take their medicine.

2)  Medical record on key ring that is updated at each visit.

3)  Print Medications and summary of visit for each patient at each visit as patients may forget what you tell them during the encounter.

4)  Make patients caregivers/family aware of any changes in patient’s care

5)  In-home care providers can be very helpful when needed

6)  Involve the patient in the decision making as much as possible

7)  Be careful about any medications that may cause drowsiness or falls

8.   Work with specialists and coordinate patient care with all upcoming appointments written down on their calendar

9)  A home visit will allow you to assess the patients environment and get them home equipment which will help keep them independent.  Some examples are:     Shower Chair, Raised toilet seats, bathtub/shower grab bars, Bed rails, Hospital type bed that can be adjusted to prop the patient up or an Over Bed Table.

One of the most fulfilling parts of my career is helping elderly patients retain their independence, and stay at home for as long as they can.  I enjoy working with family members to help make this possible.

This document is for informational purposes only, and should not be considered medical advice for any individual patient.  If you have questions please contact your medical provider.

 

I hope that you have found this information useful.  Wishing you the best of health,

Scott Rennie, DO

Blog: https://doctorrennie.wordpress.com

Nine Tips for Accessible Travel by Your Elderly Parents

by Candy B. Harrington

Are your elderly parents reluctant to travel because they just don’t get around like they used to? Well they’re not alone. According to the 2002 US Census, nearly 23 million people had difficulty standing for an hour, while 21 million people had difficulty walking up a flight of 10 stairs.

But that doesn’t mean globetrotting is out of the question for senior citizens; in fact, with a little advance planning your parents can still enjoy travel. Here are a few tips to share with them, before they make their next trip.

• Even if you can walk, reserve an airport wheelchair if you tire easily. Some airports are huge and you could easily put on several miles while in transit, and arrive at your destination exhausted.

• You are not required to remove your shoes at the airport security checkpoint if you are physically unable to do so. Just tell the TSA agent that you can’t do it, and they will hand wand you and swab your shoes for explosive residue.

• Tell the gate agent that you would like to pre-board the aircraft. This means that you will board before the rest of the passengers. Pre-boarding allows you to take things at your own pace, and gives you a little extra time to get settled in your seat.

• If you need wheelchair-accessible transportation from the airport to your hotel, choose a hotel that has a free airport shuttle. Under the Americans with Disabilities Act, if the hotel provides free transfers, they must also provide free accessible transfers, even if they have to contract out the service.

• Cruises are a great accessible travel choice, but new cruise ships are huge and it can be very tiring to walk from one end to the other. If fatigue is a factor, rent an electric scooter and have it delivered directly to your stateroom. Check with the cruise line for their approved vendors.

• If you drive to the cruise departure port, remember that parking is free at all Florida cruise ship piers for cruise passengers who have permanent accessibility modifications installed on their vehicles.

• If you tire easily, be sure and request a hotel room near the elevator. For safety’s sake, it’s also advisable to ask for a ground floor room whenever possible.

• Remember, in Europe the first floor is not at street level, so if you want a room at street level, ask for a room on the ground floor. Many small European hotels only have stairway access to the first floor, and if they have an elevator it’s usually very small.

• Don’t forget to pack your accessible parking placard with you whenever you travel. It’s good everywhere in the US (except for New York City), Canada and Europe.

Finally, encourage your parents to do extensive pre-trip research, and expand their horizons. There really are a lot of accessible travel offerings out there and the internet is a great place to find updated access information.

Candy Harrington is the editor of Emerging Horizons and the author of Barrier-Free Travel; A Nuts and Bolt Guide for Wheelers and Slow Walkers. She blogs regularly about accessible travel issues atwww.BarrierFreeTravels.com.

See Related Accessible Travel Articles
For tips and information about finding and booking an accessible hotel room, read Finding an Accessible Room Beyond ADA Compliance.

If you’d prefer to rent a house instead, read In Search of an Accessible Vacation Home.