Outcomes of elderly burn patients requiring hospitalization

Abstract

Background: The elderly population is more likely to be affected by accidents, such as burns, compared to younger populations because of their diminished host defense. There is limited data about the outcomes of elderly burn patients requiring hospitalization.

Methods: In this retrospective study, we assessed the epidemiology and outcomes of burn injuries in elderly patients (>60 years old) admitted to a burn unit of a tertiary medical center based on patient characteristics, type and extent of burns, treatment, hospital stay and mortality rates.

Results: Forty-eight elderly burn patients among 870 burn patients during the study period were evaluated. Fire was the most common cause of burns (77.1%). Most of the burns involved more than 20% of total body surface area. Twenty-six (54.2%) patients died during hospitalization. Although burn surface area slightly and non-significantly increased in patients over 75 years, there was a significantly increased mortality rate in these patients. Multivariate linear regression analysis revealed burn area and age as independent associates of mortality.

Conclusion: Our data show a high mortality rate in elderly burn patients. Extensive burns and increased age seem to increase the mortality risk.

• Burn
• elderly patients
• hospitalization
• mortality

Introduction

Along with the global aging, the older population in Turkey is expanding. Older people are vulnerable to aggressive burns because of skin atrophy, comorbidities, diminished host defense mechanisms and reduced mobility. Older people are more prone to complications of burns, and they have longer hospital stays and higher mortality rates [1–4]. Worldwide epidemiological research has revealed results and conclusions that reflect unique issues for each country related to burns in the older people [1–16]. However, there is a lacking data about the consequences of burns in older people in Turkey. This retrospective study investigated burn patients older than 60 years who were admitted to Uludag University Burn Unit during a period of 14 years.

The aim of this study was to assess the epidemiology and outcomes of burn injuries involving the older population.

Methods

In this retrospective study, we manually explored the files of all burn patients who required hospitalization. Of the 870 burn patients who were treated in our unit between 1997 (the year in which the burn unit was established) and 2011, 48 (5.5%) were above 60 years old and were included in this study. The study was conducted according to the principles of the Declaration of Helsinki.

The policy at our burn unit is to admit any burned patient older than 60 years who meets any of the American burn association major burn injury criteria:

1. >10% total body surface area (TBSA) burned.

2. Localized deep burn affecting ≥5% TBSA.

3. Facial burn.

4. Suspected inhalation injury.

5. Hands, feet or perineum burns.

6. Chemical or electrical burns.

7. Associated fracture or chronic illness.

All patients received first aid in the reception room of the emergency unit. There, intravenous access was established, the respiratory airway was cleared and endotracheal intubation was performed, if necessary. The burn patient was then transferred to the burn unit. The burned area was dressed using 1% silver sulfadiazine. Each elderly patient was evaluated on an individual basis, and excision/grafting was not performed in situations where a previous chronic illness was identified, such as severe, uncontrolled diabetes mellitus or aggravated cardiovascular diseases. The parameters investigated in this study were patient characteristics, type and extent of burns, treatment, hospital stay and mortality rates.

Statistical analysis

Statistical analyses were performed using SPSS version 13 for Windows (SPSS Inc. Chicago, IL)’. Categorical variables are presented as counts and percentages. Continuous data are presented with mean ± standard deviations. Categorical variables are compared using chi-square test and continuous variables are compared using Student’s t-test. Gender, age, TBSA and burn type were included in linear regression analysis to define independent associates of mortality.

Results

Of the 48 elderly patients, 27 were men and 21 were women with a mean age of 73.3 ± 9.9 years (range, 60–100 years). The corresponding mean ages of females and males were 74.8 ± 9.3 and 72.2 ± 10.4 years, respectively. Twenty-four (50%) of the patients, 12 (44.4%) males and 12 (57.1%) females were of ≥75 years old.

The incidence of burns was higher during the cold months, with 37.5% (18 patients) of all burns occurring during the winter (December–February) and 29.1% (14 patients) occurring during the autumn months.

Twenty-two patients (45.8%) lived in urban areas and 26 (54.2%) were from low income families. The home was the most common location where burns occurred.

Figure 1 illustrates the percentage of the different types of burns. Fire was the most common factor involved in the majority of these cases. Six patients (12.5%) suffered from scalding. Hot water was the liquid involved in the majority of these cases. Three patients (6.3%) suffered electrical burns. Two of the admitted patients had inhalation injuries in addition to fire burns. Also two patients suffered from chemical burn and one patient suffered from steam burn. Eight patients (16.6%) sustained burns involving less than 10% TBSA; 14 (29.1%) sustained burns of 10–20% TBSA; 12 (25%) sustained burns of 20–40% TBSA; and 14 (29.1%) sustained burns of greater than 40% TBSA.

Figure 1. Percentages of burn types.

Twenty-four (50%) of the 48 admitted patients were treated with excision and grafting during their second week at the hospital. Eleven (22.9%) patients underwent fasciotomy and escharotomy. The remainder of the group was treated with medical therapy and supportive measures. The average hospital stay for the 48 admitted cases was 14.5 days, and the range was 1–74 days. The mean hospital stay for the exitus group was 11.1 days, and for the survivor group it was 23.71 days (p = 0.006).

Mortality and morbidity

Twenty-six (54.2%) of the 48 elderly burn patients died during the hospitalization. The mean age of the patients who died was 78.2 ± 9.4 years and the mean age of survivors was 67.5 ± 7.5 years (p < 0.001). Fire burns tended to cause more deaths than scalding burns (25 patients (67.6%) versus one patient (20%), p = 0.06). Fourteen (53.8%) of the deceased patients had sustained burns of ≥40% TBSA; seven (26.9%) had received burns of 20–40% TBSA; and five (19%) had received burns to 10–20% TBSA. The mean TBSA was 44% in the patients who died and 14% in survivors. The mortality rate in patients with burns ≥40% TBSA was 100%, while it was 33.3% in patients with burns less than 40% of TBSA (p < 0.001). Although burns >40% TBSA was not significantly increased in patients ≥75 years old (37.5 vs. 25% in patients ≥75 years and <75 years old respectively, p = 0.35), patients ≥75 years old had increased mortality rate compared to younger patients (79.2 versus 29.2%, p = 0.001). Figure 2 depicts the relationship between mortality and the TBSA burned in the hospitalized patients.

Figure 2. Mortality and TBSA.

Linear regression analysis revealed TBSA (t = 5.3, 95% confidence interval 0.008–0.018, p < 0.001) and age (t = 3.4, 95% confidence interval 0.008–0.03, p = 0.002) as independent associates of mortality.

Discussion

In this study, we found a rather high frequency of mortality in elderly burn patients requiring hospitalization. The most frequent cause was fire burns and occurred in winter and autumn. Although older age was not significantly associated with more extensive burns, increased age seemed to independently increase the mortality risk. Furthermore, extensive burns were significantly associated with an increased mortality risk.

Burn accidents cause relatively more morbidity and mortality in the elderly population because age has an effect on the types of burns and the efficacy of clinical treatment. In this study, the elderly group was defined as individuals over 60 years old because of the shorter average life expectancy in Turkey relative to European countries.

The mean age of exitus group was 78.2 in our study. Recent data demonstrate that mortality rates rise with increasing age [5–10]. Our data suggest that although the burn surface area tends to increase with increasing age, there is a significantly higher mortality rate in patients over 75 years. In line with the results of other studies [6,8], we did not observe any gender effects in burn victims despite the higher age of female patients in our study.

In Turkey, individuals who live in rural regions use stoves for heating, and in those areas, the water supply systems are insufficient and kerosene stoves are used to heat water for bathing; thus, burn accidents are higher during the autumn and winter months. Moreover, the etiology associated with this parameter and the most common etiologic factor is fire. However, the effect of etiologic factors on mortality rates could not be estimated because of fewer incidences of other etiologic factors in this study including scalding, electrical burns and chemical injury. In our study, all of the patients who underwent escharotomy and fasciotomy died possibly because these individuals had more extensive burns. When the patient could move directly to the second surgical stage, which consists of debridement and split thickness skin graft operation, mortality rates decreased as it is previously reported [7,17–20].

Our mortality rate of 54.2% is relatively higher compared to other studies [5,8,21]. This result may be associated with the inclusion criteria of this study. According to the hospitalization data, extensive burns and major injuries were chosen.

The limitations of our study include the retrospective design, small sample size and absence of a control group.

Conclusions

Burn injuries in the elderly patients are associated with high mortality rates. To prevent burns in the geriatric population, the number of public education programs and their effectiveness should be expanded.

Declaration of interest

The authors report no declarations of interest.