BURN CARE AND PREVENTION JOURNAL

OBJECTIVES: In Egypt, the geriatric burn population faces unique challenges, and understanding the problem is crucial for effective management. Here, we examined the epidemiology and outcomes of geriatric patients presenting to the Ain Shams University burn unit, over a period from January 2019 to July 2022.
MATERIALS AND METHODS: This prospective study investigated all patients older than 60 years of age who presented to the Ain Shams University Burn Unit from January 2019 to July 2022; we compared findings with our previous work published 20 years ago, in which we examined the same population from May 1995 to October 2001. The parameters investigated were patient characteristics/demographics, seasonal and day/hour variations in burn incidence, place of residence and site where burn injury occurred, type and extent of burns, treatment and hospital stay, and morbidity/mortality rates.
RESULTS: Despite the number of geriatric patients presenting to our burn unit being higher, a lower percentage required admission. Early excision and grafting were performed with a higher frequency, which may be attributed to the fewer patients with chronic illnesses. There was a reduction in both morbidity and mortality.
CONCLUSIONS: Substantial changes have been made in recent years in the approach to geriatric burns, including with prevention strategies and early intervention, which have led to a reduction in both morbidity and mortality among our patients. Multidisciplinary care, involving a team of health care professionals, including burn and plastic surgeons, geriatricians, and occupational therapists, is necessary to address the complex needs of this population.

KEY WORDS: Burn, Egypt, Egyptian, Elderly

INTRODUCTION
Geriatric burn injuries are frequent and may posit substantial associated morbidity and mortality.¹ In burn care, old age is an important predictor of mortality among burn patients.² The elderly population is more susceptible to burn injuries because of preexisting medical conditions, impaired vision, decreased coordination, and poor mobility.^3,4

Burn injuries can result in prolonged hospitalization, disfigurement, and disability, resulting in a significant burden on health care systems and individuals.⁵ In addition, older adults with burn injuries have been shown to have short-term and long-term increased mortality rates, highlighting the importance of appropriate management and care.⁶

Geriatric burns represent a public health concern, especially in low- and middle-income countries.^5,7 In Egypt, the geriatric population with burn injuries faces unique challenges, and understanding the problem is crucial for effective management. In recent years, the incidence of burn-related injuries among older adults has increased.^7,8 Scalds are the most common cause of burns in this population, often occurring in the home environment.⁸

Our department’s burn unit, as a tertiary burn center, receives referrals from all over the country. This burn unit, established at Ain Shams University in 1995, has a capacity of 22 ward beds and 8 intensive care beds and receives thousands of cases each year since its establishment, ranging from acute burns to postburn sequelae. We present a prospective study with the goal of finding the best management after burn injuries among geriatric patients.

In this study, we prospectively investigated all patients older than 60 years of age who presented to the Ain Shams University Burn Unit from January 2019 to July 2022; we compared our results with our previous work published 20 years ago, which examined the same population from May 1995 to October 2001.⁹ Our aim was to examine the epidemiology and outcomes of burn-related injuries that affect the geriatric population.

MATERIALS AND METHODS
During our study period (January 1, 2019, to July 31, 2022), 1847 burn patients presented to our unit; 55 patients (3%) belonged to the geriatric population (aged ≥60 years). Of 1847 patients who presented to the burn unit, 369 were admitted to the hospital, with 25 (6.7%) who were geriatric patients.

The admission policy at our burn unit for patients aged 60 years and older includes any of the following criteria: (1) >10% total body surface area (TBSA) burned; (2) localized deep burn affecting ≥5% TBSA; (3) facial burns; (4) suspected inhalation injury; (5) burns to hands, feet, or perineum; (6) chemical or electrical burn; and (7) associated fracture or chronic illness. The admitted geriatric patients according to these criteria represented 62.5% of 55 geriatric patients who presented to the unit.

Our unit has a policy for early excision and grafting. Nevertheless, every patient was evaluated individually, and excision and grafting were not performed if the patient had chronic illness, such as severe uncontrolled diabetes mellitus or serious cardiovascular problems. The parameters that we investigated, similar to our previous study, included patient characteristics and demographics, seasonal and day/hour variations in burn incidence, place of residence and site where burn injury occurred, type and extent of burns, treatment and hospital stay, and morbidity and mortality rates.

RESULTS
Age and sex
Of 40 geriatric patients who presented to the burn unit, there were 18 men and 22 women; mean age was 66.2 years (range, 60-75 y). Among the 25 geriatric patients who were admitted as inpatients, mean ages for men and women were 65.3 and 70 years, respectively. The mean ages of men and women who were outpatients (n = 15) were 60.5 and 65 years, respectively.

Seasonal distribution and day/hour variation
Incidence of burn injuries was observed to be higher in the cold months than the warm months, with 47.5% (19 patients) of burns occurring in the winter (December to February) and 25% (10 patients) occurring in the spring (March to May). This has been observed to be due to the use of kerosene stoves for boiling water for the purposes of cooking and producing warmth (Figure 1).

With regard to variations in burn injury versus the time of day, incidence rose gradually from early morning, to reach a peak at 5:00 pm, and then declined again at night.

Place of residence, site, and circumstances of burn injury
Among 40 geriatric patients, 28 patients (70%) lived in urban areas and 36 (90%) were from low-income families. The patient’s home was the site of the burn incidence in 34 cases. For patients who lived in areas of poverty (slum areas), the water supply systems are insufficient and kerosene stoves are used to warm water for bathing, which explains the kitchen, followed by the bathroom, as being the most frequent rooms for burns to occur.

Among 40 geriatric patients, 8 patients (20%) had burn injuries associated with a fall; 3 were caused by a cerebrovascular accident. Epilepsy and physical disability were also predisposing factors. Eighteen patients (45%) had chronic illnesses, such as diabetes and cardiovascular illness.

Type and extent of burns
The most common cause of burn injury was scalding, with a frequency of 67.5% (27/40 patients); 11 patients (27.5%) had flame burns, and 2 patients (5%) had electrical burns. Figure 2 shows the different types of burns seen at our center among geriatric patients.

Most patients (18/40; 45%) had burns involving 10% TBSA or less. Seven patients (17.5%) had burns of 10% to 20% TBSA, 9 patients (22.5%) had burns of 20% to 40% TBSA, and 6 patients (15%) had burns of >40% TBSA. Figure 3 shows the distribution of burn extent among geriatric patients.

Treatment and hospital stay
Seven of the 25 geriatric patients who were admitted underwent early excision in the first week after the burn (28%), and 9 (36%) were treated with the intermediary approach (excision and grafting in the second week). The remaining patients were treated conservatively (eschar allowed to separate on its own). Delayed skin grafting was performed later in 5 patients (20%). The average hospital stay for the 25 admitted cases was 36 days, and the range was 5 to 80 days.

Mortality and morbidity
Of 40 geriatric patients who presented to our burn unit, 9 patients (22.5%) died. All 9 deaths were patients who had been hospitalized, representing 36% (6/25) of this group. The mean age at death was 70 years. More patients with flame burns (6 patients; 66.6%) versus scalding burns (3 patients; 33.3%) died. Of geriatric patients who died, 5 had burns of >40% TBSA, 3 had burns of 20% to 40% TBSA, and 1 had burns to 10% to 20% TBSA.

The mean TBSA and full-thickness burned surface area in these patients were 45.8% and 36.4%, respectively. Figure 4 shows the relationship between mortality and TBSA burn area in the hospitalized patients. Mortality was higher in patients with previous health problems, especially among patients with diabetes and cardiovascular problems (7/9 patients; 77%). Of 16 patients who survived, 4 (44.4%) had residual issues related to the burn injury, including minor to moderate scarring in 22.2% (2 patients) and disfiguring scarring in 11% (1 patient).

DISCUSSION
The latest census of Egypt shows people aged 40 years and younger constitute 80.9% of the total population, and people aged 60 years and older only make up 6.7% of the population,¹⁰ which is unlike the situation in more industrialized countries. Another important difference between the situation in our country and others is that elderly Egyptian people usually live with their families, which helps protect them from harm and reduces the incidence and severity of burn accidents.

When compared with our 2003 study,9 our study highlights several points. First, despite the higher number of geriatric patients who presented to our burn unit (3% vs 2.3% in our previous study), there was a lower percent required admission (62.5% vs 64.9%). Seasonal distribution remained about the same, with most burns occurring during the cold months. The distribution of burn type and extent showed little change.

In addition, compared with our earlier study,9 early excision and grafting were performed with a higher frequency (28% vs 10.3%), which may be attributed to less patients with chronic illnesses (45% vs 54.6%). According to our unit’s treatment policy, we use early excision cautiously in geriatric patients who have chronic disease, in concordance with Kirn and Luce.11 Our present study also showed a reduction in both morbidity (44.4% vs 48.4%) and mortality (22.5% vs 31.9%).

The management of geriatric burn injuries has evolved over time, with a focus on prevention, early intervention, and multidisciplinary care. In the past, the care of older adults with burn injuries was often challenging because of a lack of specialized facilities and resources. However, substantial changes have been made in the approach to geriatric burns. Prevention strategies, such as home safety assessments and education on the use of hot water and heating devices, play a crucial role in decreasing the incidence of burn injuries in the geriatric population.¹²

Multidisciplinary care, involving a team of health care professionals, including burn and plastic surgeons, geriatricians, and occupational therapists, is necessary to address the complex needs of this population.⁷

Volume: 3 Issue: 3 September 2023

FULL TEXT