Exploring the prevalence and management of wounds for people with dementia in long‐term care

Abstract

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long‐term care (LTC). A scoping literature review, a cross‐sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies andof the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence‐based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia‐specific facilities and a lack of research in this area limits evidence in guiding practice.

Key Messages.

• this is the only study found that documents the prevalence of all wound types and the assessment, management, and prevention strategies utilised for people with dementia and a wound in LTC

• the aim of this study was to determine the prevalence of wound types and current management strategies for wound care for people with dementia in long‐term care (LTC)

• skin tears were noted as the most common wound in independently mobile people with dementia; however, documentation of wounds occurred in less than a third of residents in LTC

• information gained from this research will provide much needed information to guide clinical care for people with dementia in LTC

1. INTRODUCTION

The ageing of the population in Australia, in line with other developed countries, is well documented, with the trend giving rise to an increase in incidence and prevalence of health conditions and complex health states for which age is a significant risk factor.1, 2 As the skin ages, reduced moisture and loss of elasticity places the older person at increased risk of a variety of wounds such as skin tears and pressure injuries.3 In addition, the presence of multiple comorbid conditions often increases the time to healing and places the older person at greater risk of living with a wound.

Dementia is a term used to describe a collection of symptoms caused by progressive and incurable disease affecting the brain. The damage to the brain can cause impaired cognition, behaviour, and function.4 In the later stages of dementia, cognitive decline can impair an individual's ability to process information accurately which can impact treatment plans such as wound management.

While memory loss is not a normal part of ageing, age is a risk factor for dementia and with the population ageing, it is estimated that by 2050, 900,00 Australians will have a diagnosis of dementia.5 With the population ageing in Australia and internationally, it is anticipated that the incidence of older people with dementia who have wounds will increase. While there is considerable anecdotal evidence of the overlap of these two conditions, there is a dearth of documented cases in the literature where this is collaboratively addressed.

The mean age of residents entering long‐term aged care in Australia is 80.2 years and over 50% of the LTC population have a diagnosis of cognitive impairment or dementia.6 With advancing age people with dementia in LTC, are likely to be at increased risk of developing a wound because of impaired cognition resulting in a higher incidence of falls, a higher prevalence of risk factors for falls, and altered mobility.7 Health professionals report managing wounds in adults with dementia is a frequent and challenging problem, yet people with dementia from our literature search were mostly excluded from research into evidence‐based wound care. Anecdotally, evidence from clinicians indicates that wound care treatment in people with dementia is often not tolerated and/or adhered to, which contributes to delayed healing. Understanding more about the prevalence, types of wounds and current wound practices for people with dementia will inform the direction of a program for research designed to improve the knowledge of wounds and care strategies to manage wounds in people with dementia. To this end, a review of current literature has been completed to determine the published prevalence and management of wounds for people with dementia in LTC settings and a wound audit of residents with dementia in two aged care facilities was conducted to explore the current status of the prevalence and management of wounds.

2. LITERATURE REVIEW

A scoping literature review was completed to determine what is already known in regards to wounds and people with dementia. This review aimed to highlight the gaps in the literature regarding the prevalence and management of wounds for people with dementia in LTC settings. A systematic approach was used to conduct the search in June 2018. The data bases searched included Cinahl, Medline, Cochrane, JBI, Embase, and Pubmed. Keywords used to conduct the search were (cognitive impairment OR dementia OR alzheimer's disease) AND (residential home OR nursing home OR aged care OR long‐term care) AND wound OR chronic wound or skin ulcer OR leg ulcer OR pressure ulcer OR skin tear OR wound care OR wound assessment OR wound management OR wound healing. Inclusion criteria were: (a) published in English with access to full articles and (b) related to prevalence or management of wounds in people with dementia living in LTC. Because of minimal literature, no time limit was included in the search.

A total of 336 papers were identified using this search strategy. After removing duplicates, the abstracts and titles were screened against the inclusion criteria: Nine articles were included in the final narrative synthesis (refer to Figure 1: Flowchart of Literature Review). Two reviewers independently screened the titles, abstracts, and full‐texts as appropriate of all articles based on the inclusion criteria, utilising an independent checklist that included sample characteristics, study type, prevalence of dementia/wounds, and outcomes to evaluate studies. A third reviewer moderated any discrepancies.

Figure 1.

Flowchart of literature review

2.1. Results of literature review

A total of nine studies met the inclusion criteria. No papers were found that reported best practice, wound management, and/or prevention strategies specifically for people with dementia. People with dementia from our literature search were mostly excluded from research into evidence‐based wound care. The reason for exclusions were not detailed but it can be reasonably assumed that the cognitive impairment and memory decline experienced by people with dementia could result in non‐compliance with treatment and interference with dressings and wound care products, that could lead to a potential impact on healing rates, influencing the results of these studies. This poses the question that if the impact of people with dementia is sufficiently significant to exclude them from studies into wound care, what studies are being performed to address what must be the significant factors that underpin this exclusion? These factors in themselves provide an imperative to undertake research into wound care and the management of people with dementia, whose condition places them at an increased risk of negative wound outcomes such as infection and delayed healing.

The included studies reported the prevalence and types of wounds in people with dementia in LTC (See Table 1 for summary). All studies were conducted in this decade and the majority of the studies were conducted in the United States of America.8, 9, 10, 11, 12 Other studies were conducted in Korea,13 Germany,14 Belgium,15 Brazil,16 Canada,17 and Austria.18

Table 1.

Description of literature review studies

Author/country	Aim	Study type/data source	Sample size/age	Findings
Grabowski & Mitchell/USA	To explore the association between private oversight (family visits) and the quality of end of life care for NH residents with severe dementia	Longitudinal study over 3 y. PI stage II and above was assessed by nurse interview	N = 323 NH residents with severe dementia. Mean age 85.3 y (SD 7.5)	As a measure of family oversight, the number of hours visited was categorised for residents as no visits, 1‐7 h/wk or > 7 h of visits. More than 7 h/wk of visits were concluded to be 2 times more likely to have a PI of stage II or above than residents with 1‐7 h of visits/wk. Prevalence data for PI not reported
Mitchell et al/ USA	To create a risk score to estimate survival in NH residents with advanced dementia	Retrospective cohort study in all licenced US NHs	N = 222 405 Mean age 84.5 y (SD 7.5)	14.7% had PI's stage II or greater. A mortality risk score with 12 variables (including at least one PI stage II or greater) predicting survival of 12 mo survival with moderate accuracy.
Luo et al/USA	To compare the rates of specialised care for residents with Alzheimers disease or dementia in special care unit (SCU) and other NH units and examine the associations with resident outcomes	Retrospective study of data collected from National Nursing Home Survey	N = 6234 Age ranges 65‐74 y (1.2% in SCU) 75‐84 y (2% in SCU) 85‐94 y (2.1% in SCU) 95+ y (0.9% in SCU)	SCU residents were less likely to have PI stage I or greater (7% versus 10.3%, P < .1)
Freitas and Alberti/Brazil	To estimate the capacity of the Braden Scale for predicting the onset of PIs in the home environment, and learn the incidence of PIs in this group and their associated factors	Prospective cohort study in homecare monitoring service	N = 183 Mean age of those who developed a PI was 82.5 (SD 12.1) years and those who did not develop a PI was 80.2 y (SD 10.9)	Incidence of PIs was 20% and Alzheimer's disease 17%. 81% of patients who developed a PI stage I or greater were moderated to severely cognitively impaired. People with Alzheimer's were significantly more likely to develop a PI. The use of anti‐dementia medications was also significantly associated with PI development.
Vandervoort et al/Belgium	To investigate quality of end‐of‐life care and quality of dying of NH residents with dementia	Descriptive post‐mortem study (2010) using random cluster sampling, from NH, all deceased residents with dementia in a period of 3 mo. Data gathered via questionnaire to nurse involved in care, family physician and NH administrator	198 residents in 69 NH. Mean age (at time of death) 86.7 (SD 7.0) years	54% had advanced dementia. PIs were present in 26.9%. Comparing stages of dementia revealed few differences between groups in relation to PIs.
Ahn et al/USA	Explore how pain is reported by people with dementia with a pressure ulcer	Cross‐sectional study utilising minimum data set 2.0	M = 56 577 residents with dementia in Medicare or Medicaid NHs in 2009. Mean age 84.37 y (SD 7.43)	Pressure ulcers were reported for 18% (n = 10 227) of residents with dementia. Severity of dementia was associated with experiencing more pain from a pressure ulcer with those with severe dementia and a pressure ulcer having nearly double the risk of experiencing pain.
Lahmann et al, 2015, Germany	To provide prevalence estimates of common nursing care problems in long‐term facilities and to investigate any associations between them	Secondary data analysis of 5 consecutive annual cross‐sectional multicentre studies from 2008‐2012	N = 14 798 Mean age 82.7 y (SD 10.7)	Mean prevalence for cognitive impairment was 54.1% (95% CI 53.3‐54.9) and PI 4.8% (95% CI 4.5‐5.1). The prevalence of PIs in cognitively impaired was significantly higher (5.6% versus 3.8%)
Woo et al/Canada	To describe prevalence, incidence risk of PIs and associating factors and the extent to which best practices were applied across a spectrum of health care settings	Prospective cohort study using population‐level administrative data. Data source—Ontario residents from acute care, home care, long term care or continuing care; data from RAI‐MDS and the health outcomes for better information and care (HOBIC) database from 2010‐2013	N = 203 035 Mean age in acute care: 65 y (no PI) and 74 y (with PI); home care: 64 y (no PI), 71 y (with PI), long‐term care 81 y (no PI), 81 y (with PI), hospital‐based continuing care 77 y (no PI), 77 y (with PI)	Overall prevalence of PIs 13%, highest in complex continuing care setting. Individuals with cardiovascular disease, dementia, bed mobility problems, bowel incontinence, end‐stage diseases, daily pain, weight loss and shortness of breath were more likely to develop PIs.
Schüssler et al, 2015, Austria	To compare the degree of care dependency and the prevalence of nursing care problems (PI, incontinence, malnutrition, falls, restraints) between residents with and without dementia and between the stages of dementia	Cross‐sectional design, convenience sample from two states, 9 NH, 65% response rate. Data collected by nursing staff paired with research for assessment (and records)	277 residents with and 249 residents without dementia. Mean age 85 (SD6.6) y with dementia versus 83 y (SD 9.8) y without dementia	Significantly more residents with than without dementia were completely or to a great extent care dependent (54.5 versus 16.9%). The comparison of care dependency between the stages of dementia indicated a large difference between moderate and severe dementia (completely care dependent: 9.3 versus 44.3%). No significant difference in PIs previously between residents with and without dementia. Prevalence (including stage I): 5.7% (in severe dementia); 7.2% (moderate dementia); 2.0% (mild dementia), 0 (early dementia)
Kim et al/Korea	To explore the relationship between type of NH and incidence of PI	Cross‐sectional study. Data from long term care insurance beneficiaries	N = 7841 2008‐2013 long term data set collected by the insurance company. PI incidence measured by claims submitted indicating a PI. Mean age not reported. Largest group between 80‐85 y (n = 3992, 51%)	1.2% (n = 98) of the sample developed a PI during the study period. People with dementia in LTC were 6.48 times more likely to develop a PI. The less ambulatory the person with dementia, the increased likelihood of developing a PI with 61% (n = 60) of the PIs being non‐ambulatory persons while for the ambulatory and partially ambulatory persons, PIs were seen in only 18 and 20 persons with dementia respectively.
Joyce et al/USA	To compare quality of care following admission to a NH with and without a dementia special care unit (PI was an outcome measure)	Cross‐sectional study using the National Minimal Data set	N = 704 782 residents with dementia. Fee‐for‐service Medicare eligible individuals newly admitted to the NH in 2005‐2010 Mean age 83 y	Being admitted to a special care unit was associated with a significant reduction in number of PI reported. Actual numbers of PI reported has not been reported in this paper.

Abbreviations: h, hour; LTC, long‐term care; mo, month; NH, nursing home; PI, pressure injury; SCU, special care unit; US, United States; wk, week; y, year.

The sample sizes and methods of data collection varied across the studies. The total sample size was 1 216 653 (range n = 704 78210 to n = 18316) people with dementia living in LTC. Seven of the studies had large sample sizes8, 10, 11, 12, 13, 14, 17 and utilised national data sets to collect prevalence data. The data sets included the US Minimal Data Set,8, 10 insurance company data sets,13, 17 and other aged care data sets.11, 12, 14 The studies with smaller sample sizes: Freitas et al n = 183,16 Vandervoot et al n = 198,15 Shussler et al n = 277,18 and Grabowski n = 323,9 used observation, chart audits and staff questionnaires to determine the prevalence of wounds.

The aims of the included studies also varied and included an exploration of the association between family visits and end‐of‐life care,9 development of a risk score to estimate survival in nursing home residents,12 examination of associations between care units and resident outcomes,10, 11, 13 evaluation of the Braden Scale for predicting the onset of pressure injuries (PI's)16 and investigation of quality of end‐of‐life care, and quality of dying.15 Further aims included, exploration of pain in relation to PI's,8 prevalence estimates of common nursing problems,14 best practice of PI strategies,17 and degree of care dependency between those with and without dementia.18 The only type of wounds reported in these studies was PIs.

The prevalence of PIs ranged from 26.9%15 to 1.2%.13 Stages of PI's were reported by some authors with Mitchell et al12 reporting that in a sample of residents with severe dementia (n = 222 405), 14.7% had a Stage II PI or greater.12 Ahn et al8 found that 7.7% of the study sample had a Stage I PI, 5.8% had a Stage II PI, 1.1% had a Stage III PI, and 3.4% had a Stage IV PI.8 Only one study found that there was no significant difference between the prevalence of PI's for people with and without dementia18 and one study found no differences in PI's across stages of dementia.15

Factors contributing to the development of PIs were also identified and included the presence of cognitive impairment/dementia, type of care setting, severity of dementia, and co‐morbid conditions. Lahmann et al14 found that the prevalence of PI's in people who were cognitively impaired was 5.6% as compared to those who were not cognitively impaired (3.8%) (P < .001). In addition, people with dementia living in LTC were 6.48 times more likely to develop a PI.13 Similarly Woo et al, found that PIs remained higher in people with dementia when comparing different care settings: in acute care 4.1% of people without dementia compared to 12.6% of people with dementia, home care 1.2% of people without dementia compared to 3.2% of people with dementia, and LTC 20.2% of people without dementia compared to 22.3% of people with dementia.17

Other predictors of developing a PI included the severity of cognitive impairment,16 the use of anti‐dementia medications16 and longer periods of family visitation.9 Woo et al also found that those with cardiovascular disease, dementia, bed mobility issues, bowel incontinence, end‐stage disease, daily pain, weight loss, and shortness of breath were also more at risk of developing a PI.17 Joyce et al and Luo et al both found that residents in specialist dementia units had fewer PIs compared with those in general aged care units.10, 11 This could be attributed to the mobility status of those who are admitted to dementia special care units as these units usually cater for the ambulant person. There was no evidence found of other wound types and management strategies to guide practice.

3. OBSERVATIONAL STUDY

3.1. Aim

The aim of this study was to explore the current status of the prevalence and management of wounds for people in dementia in LTC because of the lack of information found in the literature review.

3.2. Methods

Two facilities offering care for people with dementia participated in this study. Facility one was a 60 bed secure dementia unit and facility two had a secure dementia unit with 32 beds.

3.2.1. Design

A cross‐sectional observational study design was utilised. Residents with a diagnosis of dementia underwent a top to toe skin inspection to identify existing breaches of skin integrity. A medical chart audit was also conducted to confirm the diagnosis of dementia as well as documentation related to prevention, assessment, and management of any current wounds to establish the nature of the wounds (chronic or acute and aetiology).

3.2.2. Ethical consideration

Ethical approval was obtained from the university Human Research Ethics Committee and accepted by facilities involved in data collection. Because of the degree of cognitive impairment of potential participants, all residents with a diagnosis of dementia and who had an identified legal representative were eligible to participate. Information regarding the study and a consent form was sent to the legal representative of residents meeting this inclusion criteria by facility management on behalf of the research team. Signed consent forms were collected by the facility management and forwarded onto the research team. Before a skin audit was conducted, the participant was asked if they would allow us to check their skin. Verbal and non‐verbal signs of consent were observed. A member of the staff familiar with the participants escorted the research team during the skin audit to accurately identify consented residents and to minimise the level of anxiety that strangers conducting the audit could trigger.

3.2.3. Data collection

Skin integrity audit

A previously developed data collection tool for residents in LTC was utilised.19 Data collected included wound information such as number, site, type, severity, and observation of current treatments and management strategies (e.g. dressing insitu). Data collection was led by at least two members of the research team who were registered nurses with experience in wound data collection. The data collection tool included tick boxes for ease of data collection with space for free text if required. All data collectors completed a training package on wound classification, requiring a 100% success rate to be achieved before the start of data collection.

Medical records audit

A member of the research team reviewed the medical records of all participants. Both facilities used the Autumn Care medical records software which aided in the information retrieval process. The data collected from medical records included: participant age, diagnosis of dementia, wound and skin assessments, documentation of current wounds and management, wound prevention, and any care planning including allied health intervention.

3.3. Data analysis

Data from patient skin and medical record audits were analysed with the Statistical Package for the Social Science (SPSS 23.0) software. Because of small sample size, descriptive analysis only was undertaken.

3.4. Results

Skin integrity and chart audits were carried out on 34 residents. Fifty‐three percent of residents were male with a mean age of 79.59 (SD 8.75) years and 78% (n = 28) were found to have at least one wound.

3.4.1.

Wounds

The total number of wounds identified in the skin integrity audits ranged from 0 to 8 (median 3) per resident with most wounds found on the forearm (n = 11), anterior shin (n = 11), and toes (n = 10). Skin tears were the most prevalent wound type with 41% of residents with at least one skin tear, specifically 33 skin tears noted on 14 residents. Twelve percent (n = 4) of residents had one or more PI's, which included 9× stage I PIs and 1× stage II PI. Basal Cell Carcinomas/Squamous Cell Carcinomas were noted on seven residents with 12 wounds and 50% (n = 17) of residents had other wound types that included bruises (n = 12), blisters (n = 6), stoma (n = 1), Incontinence Associated Dermatitis (n = 1) and 34 scratches, open lesions, grazes, trauma, breaks, raised lesions, and/or rashes (see full results in Table 2 of the sites where wounds occurred).

Table 2.

Sites of wounds in skin integrity audit

Sites of wounds	Number of wounds
Occiput	1
Ear	2
Nose	1
Forehead/face	3
Scapula	1
Spinous process	1
Upper back area	2
Elbow	4
Forearm	11
Upper arm	3
Fingers	1
Sacrum/Coccyx	3
Ischium/buttocks	2
Knee	7
Medial Malleolus	1
Leg‐gaiter region	3
Leg‐anterior shin	11
Leg‐thigh	2
Foot‐dorsum	1
Foot‐plantar aspect	1
Toes	10
Foot‐other	3
Other	9

Evidence based practice

Sixty‐seven per cent (n = 23) of residents could reposition themselves. Pressure relieving devices were in situ for 44% of residents, mostly in the form of replacement mattresses (47% of those with pressure relieving devices), while 61% had other preventative interventions or strategies in place such as cushions, moisturisers, and/or nutrition supplements. The full results are reported in Table 3 of the pressure relieving devices in situ.

Table 3.

Pressure relieving devices in‐situ (n = 32)

Pressure relieving devices	%
Comfort and/or adjunct devices	26.7% (n = 4)
Cushions and overlays	20% (n = 3)
Replacement mattress (static, dynamic)	46.7% (n = 7)
Speciality chair	13.3% (n = 3)
Other i.e padding, pillows, hip pads	20% (n = 3)

Documentation

Both facilities had a wound assessment tool to document progress in healing; however, only 31% of residents with a wound had a wound assessment documented for the current wound. For those that had documentation related to the management of the current wound/s in the last 5 days (n = 8), the specific management strategies can be found in Table 4. An interdisciplinary team was involved in the care of residents with wounds, including Occupational Therapy in 3% (n = 1) of residents, physiotherapy in 68% (n = 23) of residents, and other health professionals (i.e. podiatrist, dietitian) involved in 62% (n = 21) of residents care.

Table 4.

Specific management strategies documented in medical records (n = 8 residents)

Documentation	%
Pressure offloading	12.5% (n = 1)
Referral	0%
Investigations	0%
Compression bandaging	0%
Risk assessment	0%
Wound assessment	100% (n = 8)
Wound photography	100% (n = 8)
Wound tracing	14.3% (n = 1)
Dressings	87.5% (n = 7)
Turning regime	0%
Organisation protocol	0%

4. DISCUSSION

The aim of this study was to review the current literature to determine the prevalence and management of wounds for people with dementia in LTC settings. This review concluded that people with dementia were mostly excluded from research into evidence‐based wound care with a lack of research in this area and no papers found that reported best practice, wound management and/or prevention strategies specifically for people with dementia or any information related to wounds other than PIs. This limited evidence in guiding practice is a significant gap in wound care guidelines and policies. This review was followed by a small pilot project of a skin and chart audit of residents with dementia in two aged care facilities to explore the current status of the prevalence and management of wounds.

The prevalence of wounds in people with dementia in this pilot trial found a median of three (range 0‐18) wounds per resident in dementia specific facilities. The overall prevalence of 78% of people with a wound in this pilot study was higher than other published data in LTC, which examined samples of all residents in LTC (mostly without dementia).19, 20 Of the wounds found in this pilot study, 20% were PIs and 70% were skin tears—a different profile to the general LTC population where skin tears had been noted to be 23% and more leg and foot ulcers were found.19 A possible explanation for this finding is the large number of participants who were independently mobile. As a result, PI was less prevalent while trauma‐related injury was more prevalent. These differences in prevalence and type of wounds found in residents with dementia suggest that current practice guidelines that focus on PI prevention and management do not meet the care needs of this population.

The lack of wound documentation in medical records is of concern when the standards for wound management stress the importance of accurate and regular documentation of wounds.21 This is necessary for a comprehensive assessment that will guide the management and prevention strategies to be put in place. This legal, chronological record of care ensures that continuity and consistency of care can occur while also ensuring appropriate interprofessional team communication towards the goals of resident care.21

While many guidelines exist on the evidence based management of wounds21 and evidence exists to support the need for appropriate documentation and specific resources on different wound types,22, 23 none of these guidelines address the issues associated with dementia/cognitive impairment. This study has highlighted the increased prevalence of certain wound types in comparison to residents without dementia, and therefore further research is needed to determine the specific challenges in relation to wound care to inform evidence based resources to assist in wound care.

5. STRENGTHS AND LIMITATIONS

The sample size of 34 residents in this study is acknowledged to be small. However, as a pilot study it has provided important data that should be considered and researched further with larger sample sizes. While not generalisable based on these numbers, further research is needed as almost all LTC facilities have a certain number of people with cognitive impairment/dementia, with numbers increasing, hence guidelines and strategies will be required to ensure optimal wound outcomes for people with dementia both in LTC facilities and also in the community. This is likely to reduce the numbers of people with a wound and reduce costs for the resident/community member, the family, and the health care system as a whole.

The use of previously trialled data collection tools will allow these research outcomes to be compared to studies of people without dementia in different health areas and the training of data collectors prior to the collection of data in the skin integrity audit ensured consistency in the data collected.

6. CONCLUSIONS

This study will benefit the community who are affected by dementia and wounds by acknowledging the issue and leading research which may potentially lead to improved health outcomes. This is the first study found that has documented the prevalence of all different wound types in people with dementia and investigated management and prevention strategies in regards to wounds in people with dementia in LTC.

This research has provided important information about prevalence, prevention, and management of wounds for people with dementia. The findings suggest that significant further research is needed to inform future guidelines on dementia‐specific prevention and management of wounds, and on translating the dementia‐specific prevention and wound management guidelines into practice. Research is also needed on identifying barriers and enablers of maintaining skin integrity to improve quality of life at different points in the dementia trajectory and in different settings.

CONFLICT OF INTEREST

The authors declare no conflicts of interest.

Parker CN, Finlayson KJ, Edwards HE, MacAndrew M. Exploring the prevalence and management of wounds for people with dementia in long‐term care. Int Wound J. 2020;17:650–659. 10.1111/iwj.13325