Elsevier

Burns

Volume 31, Issue 8, December 2005, Pages 958-963
Burns

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

https://doi.org/10.1016/j.burns.2005.06.006Get rights and content

Abstract

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.

Introduction

Burns in the elderly are devastating and often result in fatalities [1], [2], [3], [4], [5]. Burns in this age group constitute more serious injuries than in the general population and for any given burn, they have a higher mortality rate [4], [6], [7], [8], [9]. This multifactorial outcome measurement is a result of both physical and physiologic differences seen in this population. The definition of elderly in the burn literature has been variable. Some studies have included patients as young as 45 years of age [10], [11]. As a result of Americans living and working longer, as well as being active and productive for many more years, we selected 75 as the minimum inclusion criterion for age.

Diminished senses, impaired mentation, slower reaction time, reduced mobility [12], and bedridden states may lead to the decreased ability of the elderly to identify the severity of the situation as well as their capacity to escape from harm [13]. This, in turn, may lead to an increased total body surface area (TBSA) burn, deeper burns, and an increased risk of inhalation injury.

Premorbid conditions such as chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD) may lead to longer hospital stays, increased ventilation requirements, and elevated complication rates. Furthermore, Agarwal et al. demonstrated greater fluid requirements in the sickest of the elderly burn patients, leading to increases in congestive heart failure, pulmonary edema, and pneumonia [14]. Moreover, impaired response to infection and sepsis as well as the decreased ability to tolerate prolonged stress and physiologic insult may lead to increased mortality [8], [15], [16], [17], [18], [19]. Finally, the poor nutritional states commonly seen in the elderly may lead to impaired wound healing [20].

Therapy has changed considerably over the past three decades. The development of improved monitoring, resuscitation, and nutritional supplementation, in conjunction with aggressive debridement have all contributed to the reduced mortality in the elderly burn patient [20], [21], [22], [23], [24], [25], [26], [27]. Improvements in mechanical ventilation [22], [28], enhanced ulcer prophylaxis [29], [30], broadened antibiotic spectrum to combat sepsis [31], [32], better topical antibiotics [33], updated dressings such as Biobrane (Bertek Pharmaceuticals, Morgantown, WV) and Transcyte (Smith and Nephew, La Jolla, CA), as well as bio-engineered skin substitutes such as AlloDerm (Lifecell Medical, Branchburg, NJ) and Integra (Integra Life Sciences Corp., Plainsburg, NJ), have all led to increased survival in critically injured patients.

Although studies have generally demonstrated improved mortality rates in elderly burn patients in recent years, data from prior investigations have varied considerably. Furthermore, no direct comparison of outcomes, stratified by decade, has been performed. The primary objective of this study was to identify those variables that affect the mortality of the elderly burn patient and to assess how that has changed over time.

Section snippets

Materials and methods

A comprehensive, retrospective review was conducted on all patients 75 years old and older that were admitted to a university-based burn center from January of 1972 to May of 2000. Admission criteria were based on published American Burn Association guidelines. All available medical records were examined and the following variables were scrutinized: age, sex, total body surface area burn (TBSA), abbreviated burn severity index (ABSI), inhalation injury, timing of operative intervention, number

Results

A total of 201 patients, 75 years and older, were admitted to our burn unit between January 1972 and May 2000. All charts were reviewed. Stratified by decade, 41 patients presented in the 1970s, 82 in the 1980s, and 78 in the 1990s. The gender breakdown in our study included 113 males (56.2%) and 88 females (43.8%). The age distribution in our population ranged from 75 to 96 with a mean of 81 and a median of 79. The majority of the population (75%) was between 75 and 84 (Fig. 1).

Flame and flash

Discussion

As advances in medical technology continue to improve exponentially, life expectancy will continue to rise; with this, the aging of the population occurs. This trend will continue well into the 21st century and will lead to an increase in the number of elderly Americans as a percentage of the entire population. According to the U.S. Census Bureau in 2000, the population of United States citizens 75 years and older was 16,548,000 (6.0%). By 2010 this figure is projected to be 19,101,000 (6.4%),

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