Lifestyle adjustments in elderly patients after burn injury

Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes

BACKGROUND

Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management.

OBJECTIVE

Our aim was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries.

METHODS

We performed a comprehensive retrospective chart review on all patients 60 years and older with a burn injury presenting from January 2011 through September 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center.

RESULTS

A total of 459 patients 60 years and older were treated for burn injuries during the study period. Median age of burn patients was 71 years, 23.7% were 80 years and older, and 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), 17.1% had burns > 10% TBSA, and 7.8% of patients had inhalation injuries. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia.

CONCLUSIONS

Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.

Return to work after burn injury: a systematic review

Consequences of major burn injuries often include losing the ability to engage in basic life functions such as work or employment. As this is a developing area of importance in burn care, the goal of this study was to perform a systematic review of the burn literature to ascertain a comprehensive view of the literature and identify return to work (RTW) factors where possible. A search was conducted and peer-reviewed studies that investigated predictors and barriers of returning to work of those with burn injuries, published since 1970 and written in English, were examined. From the 216 articles initially identified in the search, 26 studies were determined to meet inclusion criteria. Across studies, the mean age was 33.63 years, the mean TBSA was 18.94%, and the average length of stay was 20 days. After 3.3 years (41 months) postburn, 72.03% of previously employed participants had returned to some form of work. Important factors of RTW were identified as burn location, burn size, treatment variables, age, pain, psychosocial factors, job factors, and barriers. This systematic review suggests multiple conclusions. First, there is a significant need for attention to this area of study given that nearly 28% of all burn survivors never return to any form of employment. Second, the RTW literature is in need of coherent and consistent methodological practices, such as a sound system of measurement. Finally, this review calls for increased attention to interventions designed to assist survivors' ability to function in an employed capacity.

Social issues prolong elderly burn patient hospitalization

A retrospective audit of length of hospital inpatient stay of all patients admitted to the Royal Adelaide Hospital Burns Unit over a 5-year period was performed. Data gathered from the Burns Unit database and records allowed patient division into two comparison groups: those younger than 70 years and those aged 70 years or older. Further comparison based on discharge destination was made in the ≥70 years group. Outcomes included length of stay, burn size, and discharge destination. A total of 1641 patients were included. The median length of stay was 5.0 days for patients younger than 70 years and 10.0 days for those aged 70 years or older (P < .0001). The mean percentage of TBSA burned was similar. A greater proportion of those aged 70 years or older were discharged to supported care facilities, such as nursing homes, and a greater proportion needed assessment for placement (P < .001) when compared with those younger than 70 years. The median length of stay of those aged 70 years or older who did not need assessment for placement was 9.0 days compared with 38.0 days for those who needed assessment (P < .0001). Elderly patients have, generally, nearly twice the length of stay of younger patients; when further subdivided according to discharge destination, the effect of placement delay (a social issue) becomes apparent and disturbing. This has significant implications, given the limited capacity and high cost of burn unit admission. A geriatrician will be appointed to the Burn Service over the next 12 months to assess whether earlier geriatric assessment can decrease the length of inpatient admission by facilitating a more efficient placement process.

The characteristics of elderly burns in Shanghai

OBJECTIVE

This study aims to analyse the epidemiologic characteristics of severe burn in the elderly in Shanghai and to discusses a possible prevention programme for this population.

METHODS

A retrospective review of all medical records of elderly patients (aged 60 and older) admitted with acute burns to the Burn Center of the RuiJin Hospital between January 1996 and December 2004 was carried out. Patient demographics, etiology of burn, mechanism of injury, burn extent, anatomical areas burned, number of operations, and outcomes were reviewed.

RESULTS

A total of 201 (5.8% of hospitalised patients) elderly patients (mean age (+/-SD) of 69.3+/-7.1 years (range 60-90 years)) were admitted. Majority of the patients were men (62.2%) and the most common etiologies were flames (52.7%) and scalds (39.8%). The majority of burns occurred at home (73.6%), followed by burns at workplace (15.9%) and public areas (10.5%). The median total body area burned was 11.7% (range 0-84%), and the majority of burns were classified as mild (60.2%) and moderate (32.8%). Predominant anatomical areas involved were the legs (76.1%), arms (67.2%), head and neck (49.8%) and hands (49.3%). The most common pre-injury conditions were cardiovascular diseases (25.9%), diabetes (8.5%) and neurological diseases (6%). Eighty-seven patients (43.3%) required surgical treatment. The most common complications were multiple organ failure (2%), pneumonia (1%) and wound infection (1%). Sixteen patients (8%) died: half of them in hospital, and the rest at home. There was a significant correlation between post-injury complications and death (r=0.69, p<0.001). The mean total hospitalisation cost was yen 22993.09 (US$ 3381.34).

CONCLUSIONS

Domestic and workplace burns with devastating consequences are very common in the elderly population in Shanghai. Burn prevention education and implementation of safety measures at home and at workplace would help reduce such incidences.

Burn treatment in the elderly

The population of elderly patients is expected to rise continuously over the next decades due to global demographic changes. The elderly seem to be most vulnerable to burns and their management remains undoubtedly a challenge. A clear age margin for elderly patients is not yet defined, but most studies adhere to the inclusion of patients 65 years and above, but the general condition and social situation must be taken into account. The understanding of the physiological basis of aging and its related pathophysiological changes has only marginally influenced treatment and decision making in elderly burn patients. When looking at treatment regimens currently applied in elderly burn patients, the discussion of standards in intensive care as well as surgical strategies is ongoing. However, trends towards a moderate, non-aggressive resuscitation approach and careful inclusion of key parameters like physiological age, pre-burn functional status and premorbid conditions, seem to be useful guidelines for interdisciplinary treatment decisions. Once ordered for surgical treatment, the amount of body surface area operated in one session should be adapted to the general status of the patient. Even if older burn victims have a reported higher mortality rate than younger patients, improved therapeutic options have contributed to a reduced mortality rate even in the elderly over the last decades. As a result of improved outcome, more attention has to be given to a comprehensive rehabilitation program. This review will give an overview of the current literature and will draw attention to specific topics related to this important subpopulation of burn patients.

Functional outcome after burns: a review

We conducted a Medline search (1966-11/2003) on empirical studies into the consequences of burns. The International Classification of Functioning, disabilities and health (ICF) was used to classify dimensions of functional outcome. We included 50 studies, reporting a wide spectrum of ICF-dimensions. The current state of knowledge on the functional outcome after burns was hard to summarise, due to the wide variety in study designs and outcome assessment methods. Some indications on the major functional problems after burns were gained. Problems in mental function were described in subgroups of patients, both in children/adolescents and adults. Restrictions in range of motion were observed in about one-fifth of burn patients, even 5 years after injury. Problems with appearance were reported often (up to 43%), even in patients with minor burns (14%). Problems with work were reported in 21-50% of the adult patients, with permanent incapacity for work in 1-5%. None of the publications gave sufficient information to fully estimate the functional consequences of burns. We recommend the development of a standard core set for measurement and reporting of functional outcome after burns.

A three decade analysis of factors affecting burn mortality in the elderly

This study's objective was to identify variables that affect the mortality of elderly burn patients and to assess their changes over time. A retrospective review was conducted on all patients 75 or older (n=201) admitted to a university-based burn center between 1972 and 2000. Variables examined were age, sex, TBSA, ABSI, inhalation injury, timing from burn to operative intervention, the number of surgical procedures, the number of pre-morbid conditions, and mortality. There were 95 fatalities. TBSA strongly correlated with mortality (p<0.0001). Adjusting for TBSA and inhalation injury, mortality significantly decreased (p=0.04, odds ratio=0.58). Mortality significantly increased with inhalation injury (p<0.01). Fatality risk increased by 400% with inhalation injury. Absence of inhalation injury was not significant with respect to mortality in the 1970s, however there was a significant decrease (p=0.02) in mortality without an inhalation injury in the 1980s and 1990s. ABSI was strongly predictive of mortality (p<0.0001). On average there was a 200% increase in mortality per unit increase of ABSI. The elderly are 58% less likely to die from burns now as compared to the 1970s. Although mortality rose with increasing TBSA equally in each decade, the absolute risk of mortality decreased over time. This data suggests major strides have been made in burn care, however similar success has not been achieved with inhalation injuries.

Psychosocial adjustments 5 years after burn injury

The present study investigates factors influencing the quality of life and social reintegration of burn victims. A study concept was developed to assess the functional and aesthetic long-term outcomes of burn victims. Objective data from a clinical examination was correlated with subjective data from completed questionnaires. The success of social rehabilitation was documented and an indicative profile of life quality evaluated. This profile could prompt early intervention if found necessary. Ninety-two patients were examined 5.4+/-1.1 years after trauma in relation to three factors: physical functions, localization of the burn injuries and extent of the body surface area burned. Physical functioning allows the best predictions for successful rehabilitation, because all areas of life quality are affected by it. Localization of burns in the face and hands creates disadvantages in social reintegration. Of less value in prediction is the extent of the body surface area burned, which is only closely linked to occupational rehabilitation and directly correlates to physical functional limitations. Our correlation showed, that even slight functional limitations were linked to severe depressions, similar to the values found with patients with serious functional impairment. Interdisciplinary cooperation between plastic surgeons and psychosomatic specialists will optimize early intervention with patients exposed to social maladaptation.

Thermal Injury in the Elderly: When is Comfort Care the Right Choice?

The factors contributing to a higher mortality rate in elderly thermal injury victims are not well delineated. The purpose of this study is to determine the impact of the initial injury, medical comorbidities, and burn size on patient outcome and to determine a level of injury in this population when comfort care is an appropriate first choice. Individual medical records of patients over 65 years of age admitted to our burn center over a 10-year interval were reviewed for patient demographics, mechanism of injury, total body surface area (TBSA) burned, medical comorbidities, use of Swan-Ganz catheters, evidence of inhalation injury, level of support, and patient outcome. The mechanisms of thermal injury were flame (68%), scald (21%) and electrical or chemical contact (11%). Twenty-six preventable bathing, cooking, and smoking-related injuries were seen (33%). The average TBSA was 25 per cent. Average length of stay varied depending on outcome. The overall mortality rate for this group was 45 per cent. Patients older than 80 years with 40 per cent or greater TBSA burned had a 100 per cent mortality rate despite aggressive treatment. Burn wound size correlated better with probability of poor outcome than age. Thermal injuries in the elderly are becoming more important with the aging of our population. Underlying medical problems—specifically chronic obstructive pulmonary disease—do play a role in increased patient morbidity and mortality. This study shows that age greater than 80 years in combination with burns greater than 40 per cent TBSA are uniformly fatal despite aggressive therapy. We believe that delaying the start of comfort-only measures in this situation only prolongs the pain and suffering for the patient, the family, and the physician.

The rate of restoration of body weight after burn injury, using the anabolic agent oxandrolone, is not age dependent

We determined the effect of age on the restoration of lost body weight and lean mass after burn injury, using the anabolic steroid oxandrolone. Patients with deep burns of 30-55% of body surface were studied when entering the recovery phase of injury, defined as resolution of the hypermetabolic, catabolic state. Patients were provided optimum nutrition and exercise alone or with the addition of oxandrolone. The rate of body weight and lean mass gain and improvement in physical function were measured over a 4-week period. Four groups were studied. A younger group, mean age of 34 years and burn size of 47+/-7% versus an older group, mean age 60 years and burn size 36+/-5%. The mean loss of body weight in the younger and older groups was 10+/-2 and 11+/-2% of total. Both groups were randomly divided into a control and oxandrolone study group. Weight restoration, 74+/-5% of which was lean mass, averaged 1.7+/-0.4 kg and 1.6+/-0.3 kg per week in the young and older oxandrolone groups. This rate was compared with 0.7+/-0.2 kg and 0.5+/-0.2 kg in the young and older control groups, with only 55% of weight gain being lean mass. These differences were statistically significant. The increase in the rate of weight gain with oxandrolone corresponded with a 30% decrease in length of stay in the burn rehabilitation unit. We concluded that the ability of an anabolic steroid to restore lean mass and physical function after burn surgery is not related to age.

Quality of life of the Spanish burn patient

This is a study of the quality of life as performed on a sample of 115 Spanish patients treated for burns in the Burn Care Unit of the Alicante General Hospital. Through the application of the sole existing scale for measuring quality of life specific to burn patients, the following percentages of alterations were obtained: 9.7% in physical domains; 14.2% in body image; 27.4% in psychological domains; and 22.5% for the complete scale. Results similar to those published by the original authors of the scale have been encountered by us and we are now able to confirm that the questionnaire "adapted and validated" in Spanish is equally capable of measuring changes in quality of life of the group studied herein.

Health status after recovery from burn injury

Outcome studies after burn injury have become increasingly important as overall mortality from injury has decreased. The present study, concerning physical and psychosocial aspects, is the second part of our larger survey of outcome after burn. The basis of our study instrument was the Abbreviated Burn Specific Health Scale. A postal survey was conducted among 315 patients aged 15-65 years, treated at Töölö Hospital Burns Unit between 11 November 1988 and 31 December 1994. The study series analysed consisted of 124 patients, whose mean total body surface area (TBSA) burned was 13.0%, mean full-thickness (FT) burns 6.2%, mean age 37 years and mean time of hospital treatment 16 days. Statistical analyses were performed with non-parametric tests and a probability level of 0.05 as the limit of statistical significance. Physical function was affected by the severity of the burn and by hand burns. Body image was influenced by FT burns but not by hand or facial injuries. Sexual life was affected by FT burns larger than 20%. Patients older than 25 years, those with TBSA greater than 30%, FT greater than 20% or time of hospitalization over one month were concerned about their general health. The effect of burns on patients' physical and psychosocial life was, however, slight, even with respect to severe injuries.

Energy Needs Are Poorly Predicted in Critically Ill Elderly

Changes in energy expenditure with age have been described, but this physiology is not routinely considered when managing critically ill elderly patients. To allow us to avoid the potential problems associated with underfeeding or overfeeding the critically ill elderly population, with approval of the human studies committee and appropriate consent from legal guardians, 25 critically ill patients over 65 years of age requiring mechanical ventilation underwent expired gas indirect calorimetry. If they had a pulmonary artery catheter in place for clinical reasons, reverse-Fick indirect calorimetry was also performed. Data obtained by indirect calorimetry was compared with commonly applied equations for predicting energy expenditure by statistical methods of correlation and limits of agreement. These 25 patients had an average age of 74 ± 1.23 (standard error of the mean) and an average APACHE II score of 15. Predictive equations correlated poorly with measured resting energy expenditure, and although they showed reasonable bias, they were imprecise in their estimation of resting energy expenditure. These data suggest that energy expenditure in critically ill, mechanically ventilated elderly patients is highly variable. Although generally overestimating energy needs, currently available equations for predicting energy expenditure in this population are associated with significant bias and imprecision, which may lead to both overfeeding and underfeeding. Although these equations may be suitable as a basis of initiating nutritional support, energy provisions should ideally be guided by indirect calorimetry.