Preventing Pressure Ulcers in Elderly Patients: Turning Protocols

The elderly often contend with various health challenges throughout their lives, from chronic pain and disease to harsh medications and demanding treatments. Elderly patients are frequently placed in nursing homes or hospitals to prevent accidental harm and to receive assistance with daily activities such as eating and personal hygiene. In these settings, many elderly individuals become bed-bound. One common and serious problem that bed-bound elderly patients face is the development of pressure ulcers (PrUs). Research indicates that turning a patient every two to four hours can reduce the rate of pressure ulcer occurrence. Recent studies demonstrate not only the efficacy of turning but also identify supplemental supportive measures, such as mattress substitution, and establish the longest effective turning interval that still results in a meaningful reduction of PrU incidence.

Pressure ulcers are a recurrent and difficult problem in hospitals and nursing homes. Nursing home residents and elderly patients frequently report pain and discomfort from ulcers that develop during prolonged bed rest. Among elderly populations at high risk, PrU prevalence at the start of studies typically ranges from 15% to nearly 25% on standard mattresses or foam overlays. While support surfaces combined with positional shifting were recognized as more costly components of PrU prevention, repositioning through bed turning has attracted significant attention due to positive study outcomes. Turning decreases pressure not only on the skin but also at the interface between bony prominences and protruding surfaces, which otherwise obstruct or diminish blood flow to surrounding tissue — a mechanism widely believed to cause PrUs.

PrUs must be considered alongside other injuries that elderly patients and nursing home residents acquire in care settings, because reducing such injuries leads to higher quality care and greater patient and resident satisfaction. As Miles, Nowicki, and Fulbrook (2014, p. 32) note, "The prevention of hospital-acquired pressure injuries (PIs) is an indicator of care quality, according to the Australian Commission on Safety and Quality in Health Care." Repositioning and redistribution of the body to reduce prolonged contact with pressure-sensitive areas effectively prevents PrUs. Beyond regular turning, evidence suggests that high-density foam mattresses distribute pressure more evenly than standard spring mattresses. Evidence also indicates that repositioning is, in practice, performed less consistently than the recommended every two hours, and additional research suggests that every two to four hours may be a more appropriate interval. Because research on quarter-turn repositioning specifically in elderly patients to minimize PrUs remains limited, no conclusive interval shorter than two to four hours has been formally recommended.

In a study by Bergstrom et al. (2013), the authors evaluated both the two-hour turning interval and the substitution of standard mattresses with high-density foam alternatives. Their findings showed that "there was no difference in PrU incidence over 3 weeks of observation between those turned at 2-, 3-, or 4-hour intervals in this population of residents using high-density foam mattresses at moderate and high risk of developing PrUs when they were repositioned consistently and skin was monitored" (Bergstrom et al., 2013, p. 1706). These results demonstrate that, as long as patients were repositioned within the recommended two-to-four-hour window, the specific interval did not produce a statistically significant difference in outcomes. Mattress substitution may have contributed to reducing PrU risk to some degree, but because the study's primary focus was on turning frequency, this variable was not fully analyzed.

The substitution of standard spring mattresses for high-density foam mattresses is an idea supported by both clinical evidence and common-sense reasoning. Spring mattresses have long been associated with insufficient support for the body's pressure points, which is why many individuals have already chosen foam alternatives in everyday settings. Even high-end retail markets now prominently feature foam mattresses based on strong consumer feedback: customers report better sleep quality and reduced pain compared to standard spring mattresses.

Although the primary focus of this paper is quarterly turning to prevent pressure ulcers, facilities that can afford the somewhat higher cost of foam mattresses will benefit from reduced reliance on frequent manual repositioning. Foam mattresses are therefore best understood as a supplement to regular turning rather than a replacement for it. Turning remains, as the evidence consistently suggests, the most effective method for reducing pressure ulcer occurrence.