Older Adults and Burns

Kristen Davidge, MD; Joel Fish, MD, MSc, FRCS(C)

Disclosures

Geriatrics and Aging. 2008;11(5):270-275. 

In This Article

Risk Factors

Total body surface area (TBSA) burned, percent full-thickness burn, and smoke inhalation injury are the most important and independent predictors of burn mortality.[8,9,12,19,20,27,29] Risk factors for burn injury in older adults are multifactorial. Comorbid conditions[3,14,24,25,27,31] such as dementia,[10,17,32] cardiorespiratory disease,[17,25] smoking,[8,10,21,32] and alcoholism[8,10,17,21,23,32] are well-known contributors to the incidence and severity of burns among older adults. Even in otherwise healthy individuals, age-related declines in reaction time, mobility, mentation, hearing, smell, and visual acuity may impair risk assessment and lead to delays in escaping harm and accessing medical care.[1,5,9,19,21,24,26,33] Skin changes experienced by older adults, including dermal atrophy, loss of dermal appendages, and thinning of the subcutaneous fat, provide little protection against thermal insults and increase the likelihood of full thickness injury.[4,6,19,34,35,36,37] Social factors such as living alone[6,24,34,38] have also been linked to burn injury among older adults, perhaps reflecting a lack of supervision and domestic support. Of concern also is a small but significant number of older individuals who have burn injuries while living in long-term care (LTC) faciliites.[38,39]

Data from the National Burn Repository (1995-2005) indicates that older burn patients have a mean percent TBSA burn of 7.4 ± 14.5% and a mean full-thickness burn area of 4.0 ± 11.8%[22]; these burns most commonly involve the extremities, followed by the trunk, the head, and neck.[6,17,19,29] Smoke inhalation injury is also clinically diagnosed in 10.4% of older individuals with burns.[22] Other major predictors of mortality among older adults include severity and number of comorbid illnesses,[9,12,15,19,26,29] pre-existing malnutrition,[40] postburn complications,[15,20,26] and increasing age.[9,12,20,26] In-hospital mortality of older persons with burns in North America averaged 18.5% over the past 10 years.[22] While this mortality rate has declined from earlier decades, it still exceeds that of younger adults. Figure 2 illustrates the effect of age on survival from burn injury according to TBSA burn. Furthermore, the TBSA burn associated with 50% mortality (LA50) surpasses 80% among young adults,[40] but decreases to 35-43.1% among adults age 60-69 years[12,40] and to 13.1% among those 80 years or over.[12] The significant effect of age on LA50 is illustrated in Figure 3. In many series, older individuals with burns exceeding 50% TBSA have a near-100% mortality rate.[8,14,28,33,34,38]

Figure 2.

Percent Mortality from Burn Injury by Age and TBSA Burn

Figure 3.

TBSA burn associated with 50% Mortality (LA50) by Age Group

Mortality early in burn injury results from intractable shock, whereas late mortality is attributable to multi-organ system failure.[41] While this is true for all age groups, the diminished physiologic reserve of older individuals limits their ability to respond to the substantial stress of thermal injury.[4,9,28] As a result, older adults with burns tend to be sicker and more difficult to treat than younger adults. They demonstrate more medical and infectious complications than other age groups due to their underlying comorbidities and generally weakened immune systems.[26] Additionally, a sizeable proportion of older adults may have some degree of protein-energy malnutrition on admission, leading to increased mortality, length of hospitalization, and rehabilitation requirements.[40] Demling[40] further revealed that older adults with moderate to severe malnutrition exhibit higher infection rates and delayed wound healing compared with age-matched controls.

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