Care of Geriatric Patients

Introduction

The quality of life in developed countries has improved over the past 50 years, increasing the average lifespan by nearly 30 years. Individuals aged 65 years and over account for 13% of the U.S. population. This “elderly” population is projected to double from 40.2 million in 2010 to 88.5 million by 2050. Such population aging is unprecedented. By 2050, the number of older adults persons in the world is expected to exceed the number of young for the first time in history. This trend presents a special challenge because older adults will constitute an ever-growing segment of the average surgeon's practice and will influence clinical decisions, ethical decisions, and healthcare costs.

A multicenter study conducted in Tokyo found that 25% of burned patients were older than 65 years of age. A systematic review of more than 186,500 patients in Europe showed that 10–16% were in this age range. In the United States, geriatric patients constitute about 10% of the major burn population. The anticipated rise in the geriatric population makes understanding age-related physiological and metabolic changes even more important for burn care professionals. The elderly and the very young are most likely to die from severe burns. Adults older than 65 years old have a mortality rate from burns that is five times the national average. Treatment of these patients remains a greater challenge than treatment of middle-aged and younger patients because lower physiological reserves and higher underlying comorbidities reduce the margin for error.

Epidemiology

Contact with flame is the main (54%) cause of burn injury. One third of injuries result from cooking accidents: scalds in 22% of cases and contact with hot objects in about 6% of cases. The latter cause is more prevalent in older adults, reflecting increased psychological and physical disability. This fact is also reflected in the rate of fire-related deaths in individuals older 75 years old, which is four times the national average. The male-to-female ratio decreases progressively as age increases, with women exceeding the number of men in the 75 years and older group (compared with the 5 : 1 male-to-female ratio for young adult burn patients). Most burns in older adults occur at home; therefore, prevention must be focused in the home environment. Prevention should also focus on the fact that 30% of geriatric patients are the victims of self-neglect, and at least 10% are the victims of elder abuse.

Outcome

Mortality rates have diminished among all age groups in recent decades. Technological progress as well as advances in fluid resuscitation, early burn wound excision, skin grafting, and pharmacotherapy have improved survival. The Baux score is calculated as a sum of age and percent total burn surface area (TBSA) and illustrates both the influence of age on outcome and the improvements in burn care: When compared over time, the score at which the survival rate reaches 0% has steadily increased from 100 in the 1940s to 130–140 in the early 2000s. However, mortality and morbidity rates remain higher in geriatric burn patients. A large registry study of Jeschke et al. reported the LD50 (50% mortality) for 50-year-old patients at burn sizes of 50% TBSA. This LD50 considerably drops to 30–40% TBSA for patients older than 65 years to only 25% for those older than 70. Pereira et al. have found in a large study of mortality trends and autopsy data that LD50 for older adults has remained steady at 35% for decades, which is disconcerting in the light of the overall improvement of burn care. Lung injury and sepsis were the most common primary causes of death noted in burn patients, and an increase in the weights of heart, lung, spleen, and liver was noted in all age groups postmortem. Pomahac et al. reported that increased levels of creatinine at the time of admission were associated with increased mortality in older adults.

Age, TBSA burned, and inhalation injury are associated with increased mortality rates. The mortality rate is 7.4% for all patients with burn injury aged 60–69 years, 12.9% for patients aged 70–79 years, and 21% for patients older than 80 years of age.

Geriatric patients also experience greater long-term disability after burn injury. Only about 50% of elderly patients with a major burn return home within the first year, and any loss of function, strength, or independence is more difficult to recover than in the younger patient population. The unique risk factors present in this population explain these statistics.

Risk Factors

A number of well-recognized risk factors are present in older adults. Increased risk of infections, pulmonary diseases, and sepsis as well as the variability of comorbidities present in these patients increase morbidity after a burn. Some of the more prominent factors are shown in Box 36.1 .