Care of the bedridden patient

Opening Vignette

Madam Hong is an 86-year-old woman who has been seeing you every 6 months for chronic disease management. Unfortunately, she recently suffered a stroke and is now bedridden. Her daughter, Liyan, who has taken on the role of her caregiver, contacted you to inquire if a home visit could be arranged due to Madam Hong’s mobility issues. She would also like guidance on what the family should watch for when caring for Madam Hong in her current functional state.

WHAT IS THE DEFINITION OF A BEDRIDDEN PATIENT?

A bedridden patient is one who is confined to a bed for 15 days or more, spends more than 90% of the time in bed and requires assistance in daily activities.[1]

HOW COMMON IS THIS IN MY PRACTICE?

The Population in Brief 2021 report[2] states that the proportion of individuals aged ≥65 years (17.6%) in Singapore is rising at a faster pace compared to the previous decade. With increasing life expectancy, this proportion is expected to rise further, reaching 23.8% by 2030. The number of citizens aged ≥80 years (n = 128,000) has doubled since 2011, making up 3.7% of the population. For the first time, the Census of Population 2020 collated data regarding difficulty in performing basic activities of daily living (ADLs).[3] The census reported that 97,600 residents aged ≥5 years (2.5% of the population) — the majority of whom were aged ≥65 years — were unable to perform or had significant difficulty performing at least one basic ADL. Additionally, 62,500 residents (1.6% of the population) had mobility-related difficulties, which is the main area of difficulty in ADLs. As of 2005, 0.5% of residents aged ≥55 years were fully bedridden.

HOW RELEVANT IS THIS TO MY PRACTICE?

The number of bedridden older adults is increasing with an ageing population.[4,5] Such patients will increasingly be unable to take care of themselves. They struggle with mobility and performing their activities of daily living. The high care needs and dependency of bedridden patients can lead to high caregiver stress.[6] Bedridden patients are also at risk of many complications[7] and have high healthcare utilisation.[8]

A general practitioner may be called upon to care for bedridden patients in the community, such as managing their chronic medical comorbidities or addressing infections and other complications that arise from being bedridden. Given the logistical challenges that bedridden patients and their caregivers face, the general practitioner is well placed to provide services to help these patients remain in the community for as long as possible.

WHAT CAN I DO IN MY PRACTICE?

Managing bedridden patients in the community presents many challenges. To ease the burden of care, healthcare professionals and caregivers should be aware of the risks and potential complications that bedridden patients may face. The aim of good medical and nursing care in the community is to optimise the patient’s symptoms, prevent complications, reduce frequent hospital admissions and avoid or delay institutionalisation. The role of the general practitioner in a multidisciplinary team, which includes other medical and community services, is crucial. The various aspects of care that can be provided to bedridden patients are listed in Box 1. The examples provided aim to assist physicians with practical steps that can be implemented in their practice, and are further elaborated in the article.

Table 1.

Dressing options for pressure ulcers. Adapted from Raetz and Wick.[11]

Type of ulcera,b	Best evidence-based recommendation	Wound filler/other options	Wraps/covers
Shallow and dry	Thin hydrocolloid Thin polyurethane foam	Transparent films Hydrogelc	Nonadherent gauze
Shallow and wet	Hydrocolloid with or without absorbent paste or powder Foam	Alginate	Nonadherent gauze or absorbent contact layer
Deep and dry	Hydrocolloid (over filler dressing) Foam	Fill with damp gauze, copolymer starch, or hydrogel	Transparent thin film, polyurethane foam, or nonadherent gauze
Deep and wet	Foam	Fill with alginate, single gauze strip/roll, foam, or other absorbent dressing	Transparent thin film or polyurethane foam
Fragile or friable periwound skin	Consider use of silicone dressing	–	–

Note: The objective of wound dressing is to maintain a moist environment, absorb excess exudate, facilitate autolysis, fill cavities and protect the wound from infection. Use of wet-to-dry gauze dressings should be avoided. ^aDressings are not usually needed for stage I pressure ulcers. ^bIn general, shallow ulcers are defined as stage I or II and deep ulcers as stage III or IV. ^cNot shown to be better than other standard dressings.

Common complications of immobility

Pressure ulcers

Pressure ulcers are caused when an area of skin or underlying tissue placed under unrelieved pressure is damaged due to impaired blood supply. Disruption of blood supply impedes blood flow and delivery of oxygen and nutrients to the tissues. The most common sites for pressure ulcers depend on the long-term positioning of a patient (for more information, refer to https://www.healthhub.sg/live-healthy/dont-let-the-sores-grow-on-you).

The primary aim is to prevent, rather than treat, pressure ulcers. The steps to prevent pressure ulcers include performing a comprehensive risk assessment and instituting appropriate interventions and preventive measures. Risk factors for pressure ulcers can be intrinsic (limited mobility, poor nutrition, ageing skin, significant comorbidities) or extrinsic (pressure from hard surfaces, friction, shear from involuntary movements, moisture from perspiration, bowel and bladder incontinence). The mainstay of preventive therapy is offloading and redistributing the pressure sites and preserving blood circulation. While there is currently no evidence of an optimal repositioning schedule, international guidelines recommend repositioning bedridden patients every 2–6 h depending on the risk of developing a pressure ulcer. Pressure-reducing devices, both static (e.g., foam, water, gel or air mattresses) and dynamic (e.g., alternating pressure devices, low air loss mattress), can reduce the incidence of pressure ulcers by up to 60% compared to standard hospital mattresses. There is currently no clear evidence comparing the efficacy of different pressure-reducing devices in ulcer prevention. The increased cost and noise associated with dynamic devices should be considered when selecting a product.[9]

If an ulcer has already developed, a systematic approach should be employed, including documenting and staging the ulcer with a validated scoring tool [Figure 1], planning an appropriate treatment and monitoring the progress.

Figure 1.

National Pressure Injury Advisory Panel (NPIAP) pressure injury stages.[10] Used with permission of the NPIAP (26 March 2025).

The steps for the management of pressure ulcers are summarised below.

1. Continue preventive measures

2. Wound dressings for stage 2 and above: dressings should be chosen based on wound characteristics to promote a warm and moist healing environment [Table 1].

3. Antimicrobial therapy for infected wounds, including local infection, cellulitis and osteomyelitis

4. Debridement of necrotic tissue

5. Adequate pain control, both for baseline (if any) and incident pain on repositioning, dressing and debridement

6. Assessment of nutritional status and correction of identified deficiencies

7. Referral to community facilities, including home nursing, community hospitals, polyclinics and wound clinics

8. Consider referral to a specialist or admission to a community or tertiary hospital for complex wound management

Box 1.

Role of the general practitioner in caring for bedridden patients in the community.

Aspect of care	Examples
Management of medical issues	Identify common complications (e.g., wound care, infections) and management steps that can be implemented in the community (e.g., pharmacological and non-pharmacological interventions, reducing polypharmacy)
Identification of home care needs of patient	Conduct home visits, where appropriate, to evaluate needs; provide referrals to relevant services via Agency of Integrated Care and caregiver training, where required
Provision of continuity of care	Liaise with tertiary hospitals, transitional care services and home care services; make referral to specialist services where required
Discussion regarding extent of care and patient preferences; facilitation of family conferences	Consider obtaining Advanced Care Planning Facilitator certification by Agency of Integrated Care
Provision of end-of-life care	Manage end-of-life symptoms (e.g., pain, agitation, delirium); consider enlisting hospice services where required
Provision of caregiver support	Identify signs of caregiver burden (e.g., neglect of self-care, increased emotional stress, worsening physical and mental health)

Common infections

Bedridden patients are especially prone to urinary tract infections (UTIs) and chest infections. Management of these infections involves the optimisation of risk factors, early identification of infective symptoms and initiation of necessary treatment.

The risk factors for UTIs include immobility, poor hygiene, dehydration and catheter use. These can be mitigated by physiotherapy, adequate hydration, good perineal hygiene and proper care of catheters. The risk factors for chest infections include immobility, buildup of secretions, oropharyngeal dysphagia, neurodegenerative disease, malnutrition, medications, smoking history, and environmental factors such as frequent exposure to healthcare settings. Preventive measures include physiotherapy and breathing exercises, vaccinations, assessment of swallowing and nutrition with necessary changes to diet, volume and consistency, adjustment of head position to nurse at an angle of 30°, oral hygiene and favouring home care when possible.[12]

Venous thromboembolic events

Prophylactic anticoagulation in chronically immobile patients is not routinely recommended, as the risk–benefit of such an intervention is unclear.[13] The risk of developing venous thromboembolic events (VTE) appears to decrease significantly after 4 months of immobility. Various hypotheses have been proposed, including development of spasticity, as well as venous and arterial atrophy in immobile limbs due to low oxygen requirements, both of which prevent venous stasis.[14]

Constipation

Constipation is a reduced frequency and difficulty in stool passing due to both functional and organic causes. It has a considerable impact on quality of life. Immobility is an independent risk factor for constipation and should be pre-empted and treated appropriately. Bulking agents help promote regular and soft stools. Osmotic laxatives can be helpful, but stimulant laxatives should be used with caution. Suppositories and enemas may occasionally be required. Behavioural retraining, such as setting aside a regular time for potting and bowel movement, and ensuring adequate fluid and fibre intake, are also beneficial.[15]

Nutrition

The guideline for caloric intake in an older adult is approximately 30 kcal per kg body weight per day and at least 1 g of protein per kg body weight per day. These are estimates based on individual factors such as nutritional status, physical activity (or lack thereof) and comorbidities (increased basal needs in certain conditions), and can be further adjusted.[16] Older adults should be screened for malnutrition and dehydration using a validated scoring tool (e.g. malnutrition universal screening tool) and followed up regularly to monitor their intake, preferences, weight trend and correction of any reversible underlying illnesses. Inadequate nutrition can result in sarcopenia and functional decline. Therefore, dietary restrictions that may limit intake should be reviewed and implemented only if necessary. There is no specific guideline currently for bedridden patients of other causes, but the above principles to guide nutrition would be reasonable. Referral to a dietician for assessment and co-management may be beneficial.

Depression

To become bedridden is a significant physical and mental adjustment for both the patient and his/her loved ones. Social isolation, sensory deprivation and cognitive impairment are additional risk factors for depression. It is important to look out for classic symptoms of depression (based on Diagnostic and Statistical Manual of Mental Disorders, 5^th edition diagnostic criteria) if patients are able to verbalise and are of reasonable mental status. Some validated scoring tools include Patient Health Questionnaire-9 (PHQ-9) for screening in primary care, Geriatric Depression Scale (GDS) in older adults and Endicott criteria for malignancy. Non-verbal behaviours such as shrugging, avoidance of eye contact, frowning, crying, withdrawal or aggression should also be identified.

Hygiene

It is important to ensure that the basic hygiene and grooming needs of bedridden patients are met. Such needs include bathing, dental care, regular change of clothing and bed linens, trimming of fingernails and toenails, haircuts and shaving. These can help boost the patient’s morale and self-esteem.

End-of-life care

Polypharmacy

The final months of life in patients with chronic illnesses are usually characterised by frailty and functional decline, including reaching a bedridden state. It is, therefore, important to re-evaluate treatment goals, including chronic medications. There are various validated tools to assist with deprescribing, such as Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy (STOPPFrail), Screening Tool of Older Persons’ Prescriptions (STOPP), Screening Tool to Alert to Right Treatment (START) criteria, Beers criteria and Medication Appropriateness Index.

End-of-life symptoms

Most bedridden patients suffer from a terminal illness and may experience the following symptoms near the end of life. They include, but are not limited to, pain, breathlessness, nausea, vomiting, lethargy, reduced intake, restlessness, agitation and delirium. It is important to manage the patients’ physical symptoms, and the primary care physician should consider referring to a hospice service to assist with management.

Advance care planning and preferred plan of care

Advance care planning (ACP) comprises a series of discussions to aid a patient to document future healthcare preferences based on his or her values, beliefs and wishes. Preferred plan of care (PPC) is one type of ACP and is suitable for a person suffering from life-limiting illnesses, including bedridden patients. A PPC delves into end-of-life care preferences, such as the preferred place of care (where a patient wishes to be cared for) and preferred place of death (where a patient wishes to spend the final days). If such decisions have not yet been established and the patient is no longer communicative, the attending physician should consider these discussions with the relevant and appropriate next of kin.

Community resources

The aim of care in the community is for early and timely interventions to reduce unnecessary hospital visits and admissions. Management of bedridden patients in the community can be challenging, especially if the necessary support is lacking. Physicians should watch out for signs of caregiver burnout, including, but not limited to, a caregiver’s failure to self-care, a caregiver experiencing significant levels of emotional stress, deteriorating physical and mental health. Caregivers of bedridden patients are at higher risk for burnout due to the patients’ increased dependence on them. This subsequently affects the well-being of caregivers and their ability to provide good care. Community services are available to alleviate caregiver burden.

We propose a multidisciplinary team approach to provide individualised care plans for the bedridden patient with close collaboration between the general practitioner and existing home care services. Additionally, with the evolving role of teleconsultation, it can be utilised to provide home-based care for patients. The following home care services are available to help optimise the care of such patients in their own homes and the community.

1. Home medical: A doctor who visits a patient in his/her own home to provide medical care and advice

2. Home nursing: A nurse who helps with chronic health monitoring, change of feeding tubes and wound care, and provides caregiver education and training

3. Home therapy: Home-based rehabilitation services, including physiotherapy, occupational therapy and speech therapy, to help patients in functional recovery and home modifications as required

4. Home personal care: Trained care professionals who assist the patient and caregivers with activities of daily living, medication, elder sitting and respite, mind stimulation activities and basic maintenance exercises

5. Meals-on-wheels: Meal deliveries to homebound individuals who are unable to buy or prepare meals

6. Hospice home care: A service that provides palliative care, psychological and social support and caregiver training

7. Nursing home respite care: A service that provides rest and respite for caregivers who experience significant stress and are at high risk for burnout

A range of financial schemes for patients and families are also available to reduce the burden and stress from healthcare costs:

1. Daily activities assistance: Seniors’ Mobility and Enabling Fund (provides subsidies for home healthcare items and mobility/assistive devices)

2. Mobility assistance: Pioneer Generation Disability Assistance Scheme (PioneerDAS), CareShield Life, Interim Disability Assistance Programme for the Elderly (IDAPE), Eldershield, Elderfund, Medisave Care

3. Caregiving assistance: Caregivers Training Grant, Home Caregiving Grant, Foreign Domestic Worker Levy Concession

4. Medical fees assistance: Community Health Assist Scheme (CHAS), medical fee exemption card, Medisave, MediShield Life, Medifund

The Agency for Integrated Care (AIC) is a one-stop portal that provides the aforementioned community care services to support the care of bedridden patients in a familiar environment, such as their own homes, and financial schemes for patients and families. Further information regarding care services, financial schemes, and referral and application processes can be found on the AIC website (https://www.aic.sg/).

Transitional home care services are also available for patients who experience significant or irreversible functional decline after hospital admission, helping them move from a tertiary to a community setting. While these patients may initially require hospital-level care, the inpatient setting is not an appropriate long-term place for care. The aims of transitional care services are to anticipate and tackle potential issues related to patient care, improve care continuity and ensure a smooth transition for patients from hospital to a home care setting.

Limitations to successful implementation of home care services include lack of awareness about available resources, inadequate training of healthcare professionals for home care, practical difficulties with travel and transporting of specific equipment, unsafe home environment and high costs for patients who do not qualify for subsidies.[17]

WHEN SHOULD I REFER TO A SPECIALIST?

The primary physician should seek to build rapport and align the goals of care with the patient and the next of kin when possible. Bedridden patients can be effectively managed in the community with proper coordination of resources and continuity of care.

A specialist or hospital referral may be considered when an acute event is potentially reversible, or if symptoms, complications and care needs are too complex and cannot be managed in a community setting due to limited resources. These situations include infections with sepsis, extensive bedsores that may require debridement, significant end-of-life symptoms and severe caregiver burnout. A trial of specified treatment is reasonable if it is in line with the patient’s preferences and deemed suitable by the treating physician.

TAKE HOME MESSAGES

1. The number of bedridden patients will continue to increase in an ageing population.

2. Management of bedridden patients in the community is challenging and requires a multidisciplinary approach.

3. Some common complications of immobility include pressure ulcers, infections, malnutrition, constipation, poor hygiene, depression and VTE. The primary aim of care is optimise the risk factors to prevent such complications from occurring.

4. End-of-life care discussions should be initiated proactively with the patient and/or family.

5. A variety of home care services and financial schemes are available for patients through AIC, which provides a one-stop portal for general practitioners to explore care options and make patient referrals.

Closing Vignette

During your home visit, you find that Madam Hong is a shadow of her former self. She is now non-communicative and requires a nasogastric tube for feeding. You explain to Liyan the common complications of immobility, including how to prevent pressure ulcers and how to spot early signs of infection. However, you notice that Liyan is alone and appears stressed and uncertain about her new role as a caregiver. She expresses gratitude and appears more relieved after you discuss the available home care services and teach her to recognise signs of caregiver stress. You also reassure her that you will be working closely with the relevant home care services to manage Madam Hong’s care in the community.

Conflicts of interest

There are no conflicts of interest.

SMC CATEGORY 3B CME PROGRAMME

Online Quiz: https://www.sma.org.sg/cme-programme

Deadline for submission: 6 pm, 23 May 2025

Question: Answer True or False
1. A patient is considered bedridden if he or she is confined in bed for at least 15 days for more than 90% of the time and is dependent on another person for daily activities.
2. The number of bedridden patients in Singapore is expected to decrease by 2030.
3. The majority of bedridden patients are above 65 years old.
4. The main domain of difficulty in basic activity of daily living relates to financial planning.
5. Bedridden patients have high healthcare utilisation.
6. Good medical and nursing care in the community can reduce hospital admissions.
7. Good medical and nursing care in the community does not reduce institutionalisation.
8. Poor nutrition is a risk factor for development of pressure ulcers.
9. The mainstay of preventive therapy is offloading and redistributing pressure sites and preserving blood circulation.
10. Bedridden patients should be repositioned every 24 h.
11. Long-term antibiotics should be prescribed for all pressure ulcers.
12. Influenza and pneumococcal vaccines help with reducing the risks of pneumonia in bedridden patients.
13. The risk of developing a venous thromboembolic event appears to decrease significantly after 4 months of immobility.
14. Immobility is a risk factor for constipation.
15. The STOPPFrail criteria is an example of a validated tool to assist with deprescribing in bedbound patients.
16. There is no role for advanced care planning if a patient is already bedridden.
17. There are services available to provide rest and respite for caregivers.
18. There are financial schemes available to assist with activities of daily living.
19. The Agency for Integrated Care is a one-stop portal that provides community care services to support the care of bedridden patients.
20. The aims of transitional care services are to anticipate and tackle potential issues related to patient care, improve care continuity and ensure smooth transition for patients from hospital to a home care setting.

Funding Statement

Nil.