Parkinson’s disease predominantly affects the area in the brain called as the nigrostriatum. It occurs due to the malfunction and death of the vital nerve cells in the brain called as the dopaminergic neurones which are mainly responsible for the control of movement and coordination. It is a chronic and progressive neurodegenerative disorder adversely affecting the control over the bodily movements and balance. The symptoms include shaking, rigidity, slowness of movements, difficulty with the walking, freezing of gait and frequent falls. Thinking and behavioral problems, dementia, depression, and anxiety are also common symptoms in the advanced stages of this disease. Its symptoms continue and worsen over time. Almost 1 million people in the United States are living with this disease. Although, the definitive cause is unknown and currently there is no specific cure as yet, still, there is extensive research going on for its pathogenesis, diagnosis, and treatment.
Parkinson’s disease can be very demanding on the caregivers, especially in the end stages of Parkinson’s disease, when the patient is wheelchair bound or absolutely bedridden. This is the time when extra precautions have to be taken to prevent bedsore formation. Pressure ulcer is defined as a localised injury to the skin or underlying tissue over the bony prominence, as a result of the unrelieved pressure. Bedsores (also called pressure sores or decubitus ulcers) can be extremely painful and usually develop as a result of prolonged immobilization. It is better to take precautions to prevent bedsore formation because once they develop they can progress very fast and then become extremely difficult to heal.
How and why do Bedsores form?
- Parkinson’s patients tend to have a higher propensity towards the development of bedsores. The therapies targeting the abnormality of dopamine deficiency and the effect of insufficient dopamine itself can affect the integumentary system and adversely affect or slow down the wound healing. The cutaneous denervation in the Parkinson’s disease leads to the sensory deficit in the form of alteration of the sweat glands, and a decline in the innervation to skin blood vessels and erector pilli muscles, thereby making the Parkinson’s patients to have increased threshold for the sensation of cold, warm, heat, pain, and touch. Owing to this factor, they have a higher sensitivity towards the factors causing bedsores as compared to the non parkinson’s patients.
- Due to restricted movements towards the end stages of the disease, there is constant pressure (as a result of the patient’s own body weight) on certain areas of the body such as the buttocks, hips, back of thighs or heels. This constant pressure causes loss of blood circulation to those areas and as a result the tissues die and decubitus ulcers are formed.
- Quite often, the friction caused by bed sheets when a bedridden person is moved causes the delicate and thinned-out skin (especially in the elderly patient) to break leading to bedsore formation in these areas.
- Furthermore, as a result of the various causes of weight loss in a Parkinson’s disease , the normal cushioning of the body by fat and muscles is lost. Chronic moistness of the skin due to inability to control the bladder in later stages also predispose to bedsore formation.
- So also, the imbalance caused in the muscular movement and co-ordination leads to frequent falls in the elderly population which are usually difficult to heal. As a result, the Parkinson’s patients are immobilized and hospitalized for a longer duration of time and prolonged periods of unchanged position cause the pressure sores to develop.
Symptoms of Bedsores in Parkinson’s Disease
In the early stage, there is persistent redness of the skin with slight pain or itching. If treated at this stage, bedsores usually heal rapidly. If not detected early enough, blisters or open sores may form with reddish discoloration of the surrounding skin, which may soon progress to a crater-like ulcer which gradually becomes more painful. In extreme cases, very deep ulcers are formed which involve the deeper structures such as muscles, bones and nerves and can be excruciatingly painful.
Prevention of Bedsores in Parkinson’s Disease
- Caregivers have to be extremely alert to the first signs of a bedsore such as persistent redness of the skin, especially at pressure points of the body.
- Pressure reduction to preserve microcirculation is the mainstay of preventive therapy. Relieving of pressure by turning the patient on his side frequently will prevent formation of bedsores or their further progression. The caregiver of the patient must strictly follow a patient’s repositioning schedule. However, there is no evidence to determine an optimal patient repositioning schedule, yet, according to the recommendations from the Agency for Health Care Policy and Research, the bedridden patients should be repositioned every two hours. Some patients, however, can reduce the pressure by repositioning themselves with the help of manual aids such as bed side trapeze bar.
- Keep the head of the bed at the lowest safe elevation to prevent shear. Head of the bed should not be elevated to more than 30 degrees
- Use pressure reducing surfaces like water mattresses and air mattresses.
- Eating a healthy balanced diet and provide supplementation if needed, keeping the skin clean and dry, and physiotherapy and exercises for a Parkinson’s disease patient help to prevent bedsores.
- If in case an ulcer develops, documentation of each ulcer in terms of its size, location, granulation tissue, eschar, undermining, infection, exudate and sinus tracts are essential to do the appropriate staging for the wound assessment and subsequent treatment.
Complications of Bedsores in Parkinson’s Disease
Infection of the skin and adjoining tissues and deeper structures such as muscles, bones and joints. Extreme pain due to involvement of the nerve is another complication.
Treatment of Bedsores in Parkinson’s Disease
- Wound cleansing by normal saline and dressing is the mainstay of ulcer treatment.
- Management of the local and distant associated infections.
- Remove the necrotic tissue by wound debridement. Perform an urgent and a sharp debridement in case advancing cellulitis or sepsis. In case of non urgent debridement, use mechanical, enzymatic or autolytic debridement methods.
- Maintain a moist environment for wound healing
- Relieving of pressure by changing positions often, such as by turning the bedridden patient frequently.
- Using special cushions or mattresses.
- A healthy nutritious diet.
- Controlling incontinence of urine or using incontinence pads.
- Proper cleaning of the wound.
- Removal of dead or damaged tissue.
- Regular dressing of the bedsore.
- Use of local antiseptic creams.
- Antibiotics. The use of topical antibiotics is considered if there is no improvement or healing even after 14 days. Systemic antibiotics are usually used in patients with osteomyelitis, advancing cellulitis, diabetes mellitus, or some other associated systemic infection.
- Pain relievers.
- Surgical treatment is the last option in later stages.