J Wound Ostomy Continence Nurs. 2015;42(4):352-359. Published by Lippincott Williams & Wilkins
WOUND CARE
Health-Related Quality of Life in Elderly Patients With Pressure Ulcers in Different Care Settings Diba Maria Sebba Tosta de Souza Daniela Francescato Veiga Ivan Dunshee de Abranches Oliveira Santos Luiz Eduardo Felipe Abla Yara Juliano Lydia Masako Ferreira
■ ABSTRACT PURPOSE: The purpose of this study was to measure and compare health-related quality of life in elderly patients with pressure ulcers in different health care settings (home care acute care facility, and long-term care facility [LTCF]). DESIGN: Cross-sectional comparative study. SUBJECTS AND SETTING: One hundred ten elderly patients with (n = 36) and without (n = 74) pressure ulcers living in LTCFs, hospitals, or at home. The research setting included 1 tertiary and 2 community-based hospitals, 10 LTCFs, and 18 community health centers in Brazil. METHODS: The Mini-Mental State Examination, Braden Scale for Predicting Pressure Sore Risk, and Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) were used to assess cognitive status, pressure ulcer risk, and health-related quality of life, respectively. RESULTS: Compared with those without pressure ulcers, elderly patients with pressure ulcers reported significantly lower (worse) SF-36 scores on physical functioning (P < .001) and role physical (P < .05) in all settings, and on social functioning (P = .045) and role emotional (P = .036) in LTCFs. Subjects in hospitals with pressure ulcers scored significantly higher (better) SF-36 scores on mental health (P = .046) and vitality (P = .009). Hospitalized patients without pressure ulcers had lower SF-36 scores on bodily pain (P = .007) and general health (P = .026) than those living in LTCFs or at home. Patients without pressure ulcers in LTCFs had significantly lower MiniMental State Examination scores (lower cognitive status) than those living in other settings (P = .001). CONCLUSIONS: Elderly patients with pressure ulcers who were hospitalized and living at home or in LTCFs reported low scores on physical functioning and role physical, and LTCF residents also reported low scores on social functioning and role emotional. This shows the need for an environment that includes health care profession-
352 J WOCN ■ July/August 2015
als prepared to implement strategies for pressure ulcer prevention. KEY WORDS: Aged, Cognition, Pressure ulcer, Quality of life, Risk factors
■ Introduction The World Health Organization defines health-related quality of life (HRQOL) as the “individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.”1(p1404) Determining an individual’s quality of life requires a multidimensional evaluation based on intrapersonal and social-normative criteria of the person-environment system at a given time.2 Research has identified multiple
Diba Maria Sebba Tosta de Souza, RN, PhD, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, and Department of Nursing, Universidade do Vale do Sapucaí (UNIVÁS), Pouso Alegre, MG, Brazil. Daniela Francescato Veiga, MD, PhD, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, and Division of Plastic Surgery, UNIVÁS, Pouso Alegre, MG, Brazil. Ivan Dunshee de Abranches Oliveira Santos, MD, PhD, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. Luiz Eduardo Felipe Abla, MD, PhD, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. Yara Juliano, PhD, Department of Biostatistics, UNIVÁS, Pouso Alegre, Minas Gerais, Brazil. Lydia Masako Ferreira, MD, PhD, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. All authors also declare no conflict of interest or competing financial interests with regard to the manuscript. Correspondence: Daniela Francescato Veiga, MD, PhD, Rua Napoleão de Barros 715, 4o. andar, CEP 040024–002 São Paulo, SP, Brazil ([email protected]). DOI: 10.1097/WON.0000000000000142
Copyright © 2015 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00096_LR 352
24/06/15 4:53 AM
J WOCN ■ Volume 42/Number 4 HRQOL-related challenges faced by older persons, including social functioning, financial resources, self-esteem, and health problems associated with their physical environment.3-5 Strategies to improve HRQOL in the aging adult must address financial issues, diseases that lead to functional impairment, absence of at least 1 trusting relationship, and the inability to move away from a changing neighborhood.6 A recent conference about public policies related to aging with a disability highlighted 6 major areas requiring study: (1) resources to support independent living, (2) improving HRQOL and participation in daily activities, (3) performing activities of daily living, (4) role of families, (5) medical care, and (6) concerns transcending sectors.7 It was estimated that 20.6 million people living in Brazil in 2010 were aged 60 years or older.2 The aging of the population is associated with increased prevalence of chronic degenerative diseases. It is estimated that only 22.6% of Brazilians aged 60 years or older are free of chronic diseases. This proportion falls to 19.7% in Brazilians aged 75 years or older.2,8,9 Pressure ulcers affect aged persons in multiple care settings, including acute care, long-term care, and the home. Epidemiological data from Brazil have reported incidence rates for pressure ulcers as 39.4% in persons living in longterm care facilities and 40% in hospitalized elderly patients.10,11 A recent study conducted in the United States with patients 65 years of age or older who underwent surgery for hip fracture found a cumulative incidence of acquired pressure ulcers at 32 days after initial hospital admission of 36.1%.12 Badia and colleagues13 reported results of a longitudinal of 1001 elderly, dependent patients living at home; approximately 25% patients died during the 1-year follow-up period.13 Variables that independently predict mortality included existence of 1 or more pressure ulcers. While other authors have studied HRQOL in elderly patients with pressure ulcers,14-20 no studies were found comparing quality of life based on health care setting. The aim of this study was to assess and compare HRQOL in elderly patients with pressure ulcers in 3 settings: acute care, long-term care, and home care.
■ Methods A cross-sectional study design guided data collection and analysis. Study procedures were reviewed and approved by the institutional research ethics committees of each of the facilities where research was conducted; all participants signed a written informed consent. The research setting included 1 tertiary and 2 community-based hospitals, 10 long-term care facilities, and 18 community health centers where elderly patients living at home were assessed. Participating facilities were located in the cities of São Paulo (654 beds), Pouso Alegre (250 beds), and Alfenas (150 beds). Of the 10 LTCFs included in the study, 2 were
de Souza et al 353 located in Pouso Alegre, 2 in São Paulo, and 1 in Borda da Mata, Cachoeira de Minas, Conceição dos Ouros, Ipuiuna, Santa Rita do Sapucaí, and Ouro Fino, respectively. The target population was elderly persons receiving care in an acute care facility, long-term care facility, or at home. Inclusion criteria were 60 years of age or older and cognitively intact; we enrolled persons with or without pressure ulcers. Exclusion criteria were persons hospitalized for less than 24 hours or institutionalized for less than 2 months.
Instruments Cognitive status was assessed using the validated Brazilian version of the Mini-Mental State Examination,20,21 scores ranged from 0 to 30 and scores less than 19 (cutoff score) were used as an exclusion criterion of this study. The Braden Scale for Predicting Pressure Sore Risk was administered to the participants. Cumulative Braden Scale scores range from 6 to 23, with lower scores indicating higher risk; a total score of 16 (cutoff score) or less indicates increased risk for pressure-ulcer development.23 In the present study, a score of 13 and less was considered indicative of high risk for pressure-ulcer development.24 The Brazilian version of the Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was used to assess HRQOL. The SF-36 has undergone extensive validation, and the Brazilian version has also been validated.25
Study Procedures Data were collected over a 10-month period; collection required 30 to 45 minutes. The 3 instruments were administered in the following order: Mini-Mental State Examination, Braden Scale, and SF-36. The instruments were completed during interviews conducted by 3 undergraduate medical students and 1 nursing student (collaborators), who received training from the principal investigator (D.B.T.) in 4 stages. During the first stage, the collaborators were instructed about the study and they received directions concerning administration of the 3 instruments described previously. In the second stage, collaborators were taught staging and location of pressure ulcers. In the third stage, the collaborators received instruction and practical training on how to classify pressure ulcers into the different categories (stages). The fourth stage was used to evaluate the performance and agreement between collaborators.
Data Analysis Statistical analysis was performed using the Statistical Package for the Social Sciences 18.0 (SPSS Inc, Chicago, Illinois). Nonparametric tests were used for the statistical analysis. The χ2 test or the Fisher exact test was used to compare groups based on the nominal variables sex, race, education level, and comorbid diseases. The MannWhitney U Test was used to compare age and cognitive scores, Braden Scale scores, and SF-36 scores between the
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00096_LR 353
24/06/15 4:53 AM
354 de Souza et al
J WOCN
groups. The Kruskal-Wallis analysis of variance was used to compare Mini-Mental State Examination, Braden Scale, and SF-36 scores within groups in different settings. The level of significance was set at 0.05 (P < .05) for all tests.
■ Results The sample comprised 110 elderly patients; 54 (38 with and 16 without pressure ulcers) were hospitalized, 31 (11 with and 20 without pressure ulcers) were residing in longterm care facilities, and 25 (9 with and 16 without pressure ulcers) were living at home. No significant differences were found when groups were compared based on mean age, body mass index, gender, and smoking habits (Tables 1 and 2). Education level was similar among groups; most patients in LTCFs (78.5%) and those living at home (70%) were illiterate, while most hospitalized patients (73.3%) had incomplete primary educations. All hospitalized participants with pressure ulcers were whites, and this differed from subjects with pressure ulcers care for in long-term care settings or at home (P = .0307). The most common comorbid condition was hypertension, followed by endocrine disorders, heart disease, and neurological disease. The percentage of patients with neurological disease living at home was significantly higher (P = .0219) in the pressure-ulcer group (44.5%) compared with the non–pressure ulcer group (6.2%), as was the percentage of hospitalized patients with heart disease (pressure ulcer, 37.5%; non–pressure ulcer, 23.7%; P = .0238) (Table 3). Thirty-six participants had 48 pressure ulcers; most were Stage (category) II ulcers in hospitalized patients, as
■ July/August 2015
compared to Stage (category) III ulcers in long-term care facility residents and those living at home. Pressure ulcers were mostly located on the sacrococcygeal area in hospitalized patients (60.9%) and LTCF residents (26.1%), and on the heels of patients living at home (45.4%). Patients with pressure ulcers reported significantly lower Braden Scale scores than patients without pressure ulcers in all the 3 settings (P < .001), as shown in Table 1. No significant difference was found in mean MiniMental State Examination scores between patients in acute and home care settings. In contrast, patients in long-term care had lower Mini-Mental State Examination scores (indicating higher levels of cognitive impairment) than elders residing in acute or home care (P = .001) (Table 4). Comparisons between and within groups of the mean SF-36 scores for the 3 different settings are depicted in Tables 5 and 6. Patients with pressure ulcers reported significantly lower scores on the physical functioning and role physical subscales than patients without pressure ulcers in all 3 care settings (P < .001). The lowest physical functioning scores were reported by patients in log-term care, followed by those living at home and in hospital. The lowest role in the physical functioning domain was reported by patients living at home, followed by participants care for in long-term and acute care settings. Hospitalized patients without pressure ulcers reported significantly lower scores on general health than those with pressure ulcers. Residents in long-term care facilities with pressure ulcers also reported significantly lower scores on the social functioning and role emotional subscales than residents without pressure ulcers.
TABLE 1.
Comparisons Between Groups of Mean Age, Body Mass Index, and Mini-Mental State Examination, and Braden Scale Scores for the 3 Different Settings NPU Group × PU Group Hospital Variables
Age, y
LTCFs
NPU
PU
NPU
PU
NPU
PU
74
72
75
72
74
73
23
24.5
25
24.5
.550
P BMI, kg/m2
21.5
.741
.550
P MMSE scores
24 22
WOUND CARE
Health-Related Quality of Life in Elderly Patients With Pressure Ulcers in Different Care Settings Diba Maria Sebba Tosta de Souza Daniela Francescato Veiga Ivan Dunshee de Abranches Oliveira Santos Luiz Eduardo Felipe Abla Yara Juliano Lydia Masako Ferreira
■ ABSTRACT PURPOSE: The purpose of this study was to measure and compare health-related quality of life in elderly patients with pressure ulcers in different health care settings (home care acute care facility, and long-term care facility [LTCF]). DESIGN: Cross-sectional comparative study. SUBJECTS AND SETTING: One hundred ten elderly patients with (n = 36) and without (n = 74) pressure ulcers living in LTCFs, hospitals, or at home. The research setting included 1 tertiary and 2 community-based hospitals, 10 LTCFs, and 18 community health centers in Brazil. METHODS: The Mini-Mental State Examination, Braden Scale for Predicting Pressure Sore Risk, and Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) were used to assess cognitive status, pressure ulcer risk, and health-related quality of life, respectively. RESULTS: Compared with those without pressure ulcers, elderly patients with pressure ulcers reported significantly lower (worse) SF-36 scores on physical functioning (P < .001) and role physical (P < .05) in all settings, and on social functioning (P = .045) and role emotional (P = .036) in LTCFs. Subjects in hospitals with pressure ulcers scored significantly higher (better) SF-36 scores on mental health (P = .046) and vitality (P = .009). Hospitalized patients without pressure ulcers had lower SF-36 scores on bodily pain (P = .007) and general health (P = .026) than those living in LTCFs or at home. Patients without pressure ulcers in LTCFs had significantly lower MiniMental State Examination scores (lower cognitive status) than those living in other settings (P = .001). CONCLUSIONS: Elderly patients with pressure ulcers who were hospitalized and living at home or in LTCFs reported low scores on physical functioning and role physical, and LTCF residents also reported low scores on social functioning and role emotional. This shows the need for an environment that includes health care profession-
352 J WOCN ■ July/August 2015
als prepared to implement strategies for pressure ulcer prevention. KEY WORDS: Aged, Cognition, Pressure ulcer, Quality of life, Risk factors
■ Introduction The World Health Organization defines health-related quality of life (HRQOL) as the “individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns.”1(p1404) Determining an individual’s quality of life requires a multidimensional evaluation based on intrapersonal and social-normative criteria of the person-environment system at a given time.2 Research has identified multiple
Diba Maria Sebba Tosta de Souza, RN, PhD, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, and Department of Nursing, Universidade do Vale do Sapucaí (UNIVÁS), Pouso Alegre, MG, Brazil. Daniela Francescato Veiga, MD, PhD, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, and Division of Plastic Surgery, UNIVÁS, Pouso Alegre, MG, Brazil. Ivan Dunshee de Abranches Oliveira Santos, MD, PhD, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. Luiz Eduardo Felipe Abla, MD, PhD, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. Yara Juliano, PhD, Department of Biostatistics, UNIVÁS, Pouso Alegre, Minas Gerais, Brazil. Lydia Masako Ferreira, MD, PhD, Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. All authors also declare no conflict of interest or competing financial interests with regard to the manuscript. Correspondence: Daniela Francescato Veiga, MD, PhD, Rua Napoleão de Barros 715, 4o. andar, CEP 040024–002 São Paulo, SP, Brazil ([email protected]). DOI: 10.1097/WON.0000000000000142
Copyright © 2015 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00096_LR 352
24/06/15 4:53 AM
J WOCN ■ Volume 42/Number 4 HRQOL-related challenges faced by older persons, including social functioning, financial resources, self-esteem, and health problems associated with their physical environment.3-5 Strategies to improve HRQOL in the aging adult must address financial issues, diseases that lead to functional impairment, absence of at least 1 trusting relationship, and the inability to move away from a changing neighborhood.6 A recent conference about public policies related to aging with a disability highlighted 6 major areas requiring study: (1) resources to support independent living, (2) improving HRQOL and participation in daily activities, (3) performing activities of daily living, (4) role of families, (5) medical care, and (6) concerns transcending sectors.7 It was estimated that 20.6 million people living in Brazil in 2010 were aged 60 years or older.2 The aging of the population is associated with increased prevalence of chronic degenerative diseases. It is estimated that only 22.6% of Brazilians aged 60 years or older are free of chronic diseases. This proportion falls to 19.7% in Brazilians aged 75 years or older.2,8,9 Pressure ulcers affect aged persons in multiple care settings, including acute care, long-term care, and the home. Epidemiological data from Brazil have reported incidence rates for pressure ulcers as 39.4% in persons living in longterm care facilities and 40% in hospitalized elderly patients.10,11 A recent study conducted in the United States with patients 65 years of age or older who underwent surgery for hip fracture found a cumulative incidence of acquired pressure ulcers at 32 days after initial hospital admission of 36.1%.12 Badia and colleagues13 reported results of a longitudinal of 1001 elderly, dependent patients living at home; approximately 25% patients died during the 1-year follow-up period.13 Variables that independently predict mortality included existence of 1 or more pressure ulcers. While other authors have studied HRQOL in elderly patients with pressure ulcers,14-20 no studies were found comparing quality of life based on health care setting. The aim of this study was to assess and compare HRQOL in elderly patients with pressure ulcers in 3 settings: acute care, long-term care, and home care.
■ Methods A cross-sectional study design guided data collection and analysis. Study procedures were reviewed and approved by the institutional research ethics committees of each of the facilities where research was conducted; all participants signed a written informed consent. The research setting included 1 tertiary and 2 community-based hospitals, 10 long-term care facilities, and 18 community health centers where elderly patients living at home were assessed. Participating facilities were located in the cities of São Paulo (654 beds), Pouso Alegre (250 beds), and Alfenas (150 beds). Of the 10 LTCFs included in the study, 2 were
de Souza et al 353 located in Pouso Alegre, 2 in São Paulo, and 1 in Borda da Mata, Cachoeira de Minas, Conceição dos Ouros, Ipuiuna, Santa Rita do Sapucaí, and Ouro Fino, respectively. The target population was elderly persons receiving care in an acute care facility, long-term care facility, or at home. Inclusion criteria were 60 years of age or older and cognitively intact; we enrolled persons with or without pressure ulcers. Exclusion criteria were persons hospitalized for less than 24 hours or institutionalized for less than 2 months.
Instruments Cognitive status was assessed using the validated Brazilian version of the Mini-Mental State Examination,20,21 scores ranged from 0 to 30 and scores less than 19 (cutoff score) were used as an exclusion criterion of this study. The Braden Scale for Predicting Pressure Sore Risk was administered to the participants. Cumulative Braden Scale scores range from 6 to 23, with lower scores indicating higher risk; a total score of 16 (cutoff score) or less indicates increased risk for pressure-ulcer development.23 In the present study, a score of 13 and less was considered indicative of high risk for pressure-ulcer development.24 The Brazilian version of the Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was used to assess HRQOL. The SF-36 has undergone extensive validation, and the Brazilian version has also been validated.25
Study Procedures Data were collected over a 10-month period; collection required 30 to 45 minutes. The 3 instruments were administered in the following order: Mini-Mental State Examination, Braden Scale, and SF-36. The instruments were completed during interviews conducted by 3 undergraduate medical students and 1 nursing student (collaborators), who received training from the principal investigator (D.B.T.) in 4 stages. During the first stage, the collaborators were instructed about the study and they received directions concerning administration of the 3 instruments described previously. In the second stage, collaborators were taught staging and location of pressure ulcers. In the third stage, the collaborators received instruction and practical training on how to classify pressure ulcers into the different categories (stages). The fourth stage was used to evaluate the performance and agreement between collaborators.
Data Analysis Statistical analysis was performed using the Statistical Package for the Social Sciences 18.0 (SPSS Inc, Chicago, Illinois). Nonparametric tests were used for the statistical analysis. The χ2 test or the Fisher exact test was used to compare groups based on the nominal variables sex, race, education level, and comorbid diseases. The MannWhitney U Test was used to compare age and cognitive scores, Braden Scale scores, and SF-36 scores between the
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-13-00096_LR 353
24/06/15 4:53 AM
354 de Souza et al
J WOCN
groups. The Kruskal-Wallis analysis of variance was used to compare Mini-Mental State Examination, Braden Scale, and SF-36 scores within groups in different settings. The level of significance was set at 0.05 (P < .05) for all tests.
■ Results The sample comprised 110 elderly patients; 54 (38 with and 16 without pressure ulcers) were hospitalized, 31 (11 with and 20 without pressure ulcers) were residing in longterm care facilities, and 25 (9 with and 16 without pressure ulcers) were living at home. No significant differences were found when groups were compared based on mean age, body mass index, gender, and smoking habits (Tables 1 and 2). Education level was similar among groups; most patients in LTCFs (78.5%) and those living at home (70%) were illiterate, while most hospitalized patients (73.3%) had incomplete primary educations. All hospitalized participants with pressure ulcers were whites, and this differed from subjects with pressure ulcers care for in long-term care settings or at home (P = .0307). The most common comorbid condition was hypertension, followed by endocrine disorders, heart disease, and neurological disease. The percentage of patients with neurological disease living at home was significantly higher (P = .0219) in the pressure-ulcer group (44.5%) compared with the non–pressure ulcer group (6.2%), as was the percentage of hospitalized patients with heart disease (pressure ulcer, 37.5%; non–pressure ulcer, 23.7%; P = .0238) (Table 3). Thirty-six participants had 48 pressure ulcers; most were Stage (category) II ulcers in hospitalized patients, as
■ July/August 2015
compared to Stage (category) III ulcers in long-term care facility residents and those living at home. Pressure ulcers were mostly located on the sacrococcygeal area in hospitalized patients (60.9%) and LTCF residents (26.1%), and on the heels of patients living at home (45.4%). Patients with pressure ulcers reported significantly lower Braden Scale scores than patients without pressure ulcers in all the 3 settings (P < .001), as shown in Table 1. No significant difference was found in mean MiniMental State Examination scores between patients in acute and home care settings. In contrast, patients in long-term care had lower Mini-Mental State Examination scores (indicating higher levels of cognitive impairment) than elders residing in acute or home care (P = .001) (Table 4). Comparisons between and within groups of the mean SF-36 scores for the 3 different settings are depicted in Tables 5 and 6. Patients with pressure ulcers reported significantly lower scores on the physical functioning and role physical subscales than patients without pressure ulcers in all 3 care settings (P < .001). The lowest physical functioning scores were reported by patients in log-term care, followed by those living at home and in hospital. The lowest role in the physical functioning domain was reported by patients living at home, followed by participants care for in long-term and acute care settings. Hospitalized patients without pressure ulcers reported significantly lower scores on general health than those with pressure ulcers. Residents in long-term care facilities with pressure ulcers also reported significantly lower scores on the social functioning and role emotional subscales than residents without pressure ulcers.
TABLE 1.
Comparisons Between Groups of Mean Age, Body Mass Index, and Mini-Mental State Examination, and Braden Scale Scores for the 3 Different Settings NPU Group × PU Group Hospital Variables
Age, y
LTCFs
NPU
PU
NPU
PU
NPU
PU
74
72
75
72
74
73
23
24.5
25
24.5
.550
P BMI, kg/m2
21.5
.741
.550
P MMSE scores
24 22
