Age and Ageing 1988;17:111-115

P.W.MCHOLBON

SKtSKiSS "

PRESSURE SORES: EFFECT OF

PARKINSON'S DISEASE AND COGNITIVE FUNCTION ON SPONTANEOUS MOVEMENT IN BED

J.P.ROVSTON Statistician Therapeutics In the Elderty Research Group end Division of Medical Statistics. Q , ^ , p ^ g , ^ (;,, Northwick Park Hospital. Harrow, Middlesex HA1 3UJ R.J.D0B88 Senior Registrar Department of Medicine *w *"> Elderty. Bamet Goneral Hospital, Barnet Hertfordshire. EN5 3DJ

TeetinWan o u nnaas* L n l ^ Registrar Senior Hegistrar A. A. MSHMUKHt Visiting Research Worker M. J. DBIHAM Consultant

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Summary
It has previously been shown that the incidence of pressure sores is related inversely to the amount of movement made during the night. The present study of 30 in-patients of geriatric units suggests that the measurement of mean lateral displacement of the centre of gravity may better characterize those at risk than the total amount of movement. The mean displacement was reduced in Parkinson's disease and in dementia. The prevalence of pressure sores was markedly increased where Parkinson's disease and dementia coexisted.

INTRODUCTION Prediction of which patients are at risk of developing pressure sores would allow preventive measures to be properly focused. In 1962, Norton and co-workers [1] introduced a score for the risk of pressure sores, based on nursing observation of general condition, mental state, continence and daytime mobility. This is still widely used. However, Pritchard [2] found that, in a geriatric unit, the Norton Score did not distinguish adequately those at risk. Exton-Smith and Sherwin [3] have shown that the occurrence of pressure sores was related inversely to a measure of the total amount of spontaneous movement made during the night. We have studied the night-time mobility of in-patients of geriatric units, recording the lateral displacement of the patient's centre of gravity using a simplified version of the apparatus of Barbenel et al. [4] for solid-based beds. Particular reference is made to Parkinson's disease since sufferers from this condition find particular difficulty with axial rotation, whether they are upright or recumbent and despite otherwise adequate levodopa therapy [5]. Patients and Methods
Movements in bed were recorded on 4 nights in clinically stable patients undergoing rehabilitation or requiring continuing nursing care, those with hemi-, para- or tetraparesis being excluded. The nighttime movements of all eligible patients with Parkinson's disease presenting during a 6-month period were monitored, as were those of a randomly-selected group of other eligible patients from the same Address correspondence to Dr S. M. Dobbs. (Present appointment: Lecturer in Pharmaceutics, School of Pharmacy, Brunswick Square, London, WC1N 1AX.

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wards. Cognitive function was assessed using the modified Tooting Bee questionnaire, a short cognitive function test designed to test memory, orientation and concentration in geriatric units [6]. The following were noted: a diagnosis of arthritis of any type, the presence of pain, whether or not a hypnotic was being taken and any existing pressure sores. Assessment of movement in bed A system with a load-transducer under each bed leg was used to obtain a continuous plot of the lateral position of the patient's centre of gravity [7]. Each transducer consisted of a cantilever, whose deflection was sensed by a resistive strain gauge. The four strain-gauge resistor elements were connected in a bridge configuration so that the out-of-balance signal was related linearly to the position of the patient's centre of gravity across the bed. The signal was amplified, filtered, and displayed on a chart recorder to give a continuous plot of the position of the centre of gravity. The records for the hour after retiring to bed and the hour before arising in the morning were eliminated from the analysis. Rising from and returning to bed during the night produced characteristic deflections: 10-min periods before and after these events were also discarded. A section of trace of the same length was discarded around the times when the subject received attention during the night. The absolute displacement of the patient's centre of gravity was calculated from body weight and a calibration by known weight. A displacement as small as 4 mm could reliably be detected. Only displacements greater than this, and sustained for 1 min or longer, were used in the analysis. Drifts of the pen, defined as movements not completed within 0.5 min or less, were not analysed. For each night studied the number of moves by the patient greater than 4,10 and 20 mm were counted and all distances of more than 4 mm were summed. These values were adjusted proportionately according to the length of record analysed. The mean size of the movements was calculated.

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Statistical methods
The significance of associations between the characteristics of patients and the measures of their movement in bed were assessed by calculating Spearman's nonparametric correlation coefficients. The relationship of mean move size to the cognitive function score and the presence or absence of Parkinson's disease was examined by multiple linear regression analysis.

RESULTS Of the 30 patients studied, 12 had Parkinson's disease, 21 had a history of arthritis, which was a major problem in ten. Seventeen complained intermittently of pain, which was severe in four. The pain was attributed to arthritis, leg ulcers, cellulitis or cramps and was being treated accordingly. Eleven patients were receiving hypnotics. Seven had superficial pressure sores. The mean (s.d.) age was 82 (7) years and mean score out of 16 for the modified Tooting Bee Questionnaire was 7 (5). It is interesting to note that all seven patients with superficial pressure sores had Parkinson's disease. The increased frequency of pressure sores in those with Parkinson's disease was highly significant (Fisher's exact test, P<0.001). Associations between movements in bed and patient characteristics are given in the Table. Size of movements Patients with poor cognitive function and/or Parkinson's disease made relatively small movements: the mean move size of the 19 patients with a cognitive function score of 3 or less and/or Parkinson's disease [13 (5)mm] was approximately half that of the remainder of the group [25 (24)mm]. Those with Parkinson's disease as a group did not have significantly lower cognitive function scores than the rest of the

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Table. Factors influencing movements in bed in 30 patients of a geriatric unit: the relationship between patient characteristics and frequency and size of movements in bed (mean values for three consecutive nights) is expressed in terms of Spearman's rank correlation coefficient Number of moves > 4 mm Age (years) Cognitive function Idiopathic Parkinson's disease'*' Arthriti8++ Pain++ Receiving hypnotic +++ Superficial pressure score+ 0.06 -0.37 # -0.06 0.02 -0.17 -0.27 0.05 >10 mm -0.02 -0.17 -0.26 0-03 -0.06 -0.15 -0.15 >20mm -0.05 0.03 -0.31 0.09 0.03 0.02 -0.21 Total distance - moved (mm) -0.06 -0.20 -0.13 0.03 -0.09 -0.15 -0.07 Mean move size (mm) -0.26 0.54" -0.36* 0.20 0.43* 0.30 -0.41*

Patient characteristics

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V<0.05; + Scored as absent 0, present 1. ++ Scored absent 0, present 1, major problem 2. +++ No 0, yes 1. [Eleven patients were receiving nocturnal doses of hypnotic (or sedative) drugs; chlormethiazole in 3, temazepam 2, nitrazepam 2, thioridazine 2, diazepam 1 and dichloralphenazone 1]

patients (r=0.134, P > 0 . 1 ) : thus these two characteristics appeared to have independent influences on movement size. However, when the cognitive function score and the presence or absence of Parkinson's disease were included simultaneously in a multiple regression equation, only the score had a significant (/ > <0.01) effect on mean move size. Each additional point scored corresponded to an increase of 5% (on average) in the mean move size. Number of movements The number of movements correlated inversely with the cognitive function score: the 12 patients with a score of 3 or less made nearly twice as many moves per hour [mean 9 (6)] as those with a higher score [5 (3)]. The number of moves made by patients with Parkinson's disease was not significantly different from that made by the other patients. Pressure sores In the patients with pressure sores, pain had been controlled by non-narcotic analgesics. These patients had a significantly smaller mean move size [11 (2)mm] than the rest of the group [19 (16)mm]. In patients who were suffering pain, the mean size of move was significantly greater [21 (18)mm] than in those who were pain free [12 (4) mm]. This may well represent an attempt to find a more comfortable position. Hypnotics We did not evaluate quality of sleep in this study but there was no objective evidence in terms of reduction of movement in bed (see Discussion) to suggest that those who received hypnotics slept better than the rest of the group.

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DISCUSSION The amount of spontaneous movement exhibited in bed by our patients was remarkably small. Since movement of a limb, not accompanied by movement of the trunk, can displace the patient's centre of gravity laterally, many of the small displacements recorded would not have been accompanied by any useful relief of pressure on soft tissue in vulnerable areas. Indeed, our patients with pressure sores had a significant reduced mean move size compared with the others, but did not differ from them with respect to number of moves made or total distance moved. Further work is required to determine whether axial rotation is a more useful predictor of the risk of developing pressure sores than is lateral displacement of centre of gravity, and to investigate the relative importance of nocturnal mobility and other risk factors. All those with pressure sores had both Parkinson's disease and dementia. However, the major determinant of mean move size in the group as a whole was dementia, the presence or absence of Parkinson's disease having no additional effect. Increased shearing stress in the skin, consequent on tremor or rigidity in the adjacent muscle, may have added to the susceptibility to pressure sores of those with coexisting Parkinson's disease. The total amount of movement in bed decreases during sleep [8], the magnitude of the effect being dependent on the depth of sleep [9, 10]. A good night's sleep is associated with a decrease in the number of moves made, but there is no change in mean move size [11]. Hypnotics such as barbiturates, meprobamate and flurazepam have been shown to reduce the total excursion made by individuals during the night [12-14] but we were unable to detect any difference in movement between aged in-patients who did, and did not, receive hypnotic and sedative drugs. However, a different spectrum of drugs for night sedation was in use. The increased frequency of small movements found in dementia presumably simply reflected the particularly severe fragmentation of sleep found in dementia in old age [15].

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REFERENCES 1. Norton D, McLaren R, Exton-Smith AN. Pressure sores: Part 1. A study of factors concerned in the production of pressure sores and their prevention. In: An investigation ofgeriatric nursing problems in hospital. London: National Corporation for Care of Old People, 1962;194238. 2. Pritchard V. Pressure sores: calculating the risk. Nurs Times 1986;82:59-61. 3. Exton-Smith AN, Sherwin RW. The prevention of pressure sores: significance of spontaneous bodily movements. Lancet 1961;2:1124-6. 4. Barbenel C, Ferguson-Pell MW, Beale AQ. Monitoring the mobility of patients in bed. Med Biol EngComput 1985 ;23:466-8. 5. Lakke JPWF, de Jong PJ, Koppejan EH, et al. In: Rinne UK, Klinger M, Stamm G, eds. Parkinson's disease: current progress and management. Elsevier/North Holland Biomedical Press, 1980; 187-96. 6. Denham MJ. Routine normal testing in the elderly. Medicine 1978;1:1. 7. Nicholson PW, Rosenthal M, Jordan A, et al. Pressure sores: relationship of drug treatment and illness to spontaneous movement during the night. BrJ Clin Pharmacol 1986;22(2):224-5P. 8. Cox GH, Marley E. The estimation of motility during rest or sleep, J Neurol NeurvsurgPsychiatry
1959;22:57-60.

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9. Loomis AL, Harvey EN, Hobart GA. Cerebral states during sleep as studied by human brain potentials. J Exp Psychol 1937;21:127-44. 10. Blake H, Gerard RW, Kleitman N. Factors influencing brain potentials during sleep. J Neuwpkysiol 1939;2:48-60. 11. Leeman AL, O'Neill CJA, Nicholson PW, et al. Parkinson's disease in the elderly: response to and optimal spacing of night time dosing with levodopa. BrJ CHn Pharmacol 1987-,24:637-44. 12. Hinton JM, Marley E. The effects of meprobamate and pentobarbitone sodium on sleep and motility during sleep: a controlled trial with psychiatric patientB. JNeunlNeurosurgPsychiatry 1959-.22:137-40. 13. Hinton JM. The actions of amylobarbitone sodium, butobarbitone and quinalbarbitone sodium upon insomnia and nocturnal restlessness compared in psychiatric patients. BrJ Pharmacol 1961;16:82-9. 14. Crowley TJ, Hydinger-Macdonald M. Bedtime flurazepam and the human circadian rhythm of spontaneous motility. Psychopharmacology 1979;62:157-61. 15. Allan SR, Stahelin MB, Seiler WO, et al. EEG and sleep in aged hospitalised patients with senile dementia: 24 h recordings. Experientia 1983;39:249-55. Date accepted 20 June 1987

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