Patients over 75 years admitted to the National Burn Centre, Haukeland University Hospital, 2000–19

Discussion

In this article, 101 patients ≥ 75 years who were admitted to the National Burn Centre at Haukeland University Hospital in the period 2000–19 are presented. The median TBSA with burns was 11 % (0.9–80 %), 17 patients received palliative care only and almost one-third of patients died in hospital. Percentage of TBSA with burns and frailty score were associated with death.

It seems that more older patients are being offered advanced treatment than before, including extensive surgery and intensive care. We found a clear increase in the number of admissions of older burn patients during the period. This partly reflects the change in practice in 2015 for more older burn patients to be accepted for transfer, also including some with less extensive burns (4). Box 1 shows the criteria for assessing the need to refer patients to the National Burn Centre. Assessing whether an older patient with extensive burns would benefit from advanced and protracted treatment at a national treatment centre is challenging. Initial clinical assessment of the extent and the depth of a burn can be difficult (19), which can lead to the referring clinician misclassifying the severity.

Patients were mainly referred for active treatment. Based on new assessments for the depth and extent of burns upon admission to the National Burn Centre, the patient's/families' wishes and response to treatment, it may be appropriate to limit treatment and in some cases switch to palliative care. Our dataset indicates that extensive burns (> 20–25 % of TBSA), often combined with a high frailty score (CFS > 4), were associated with a poorer prognosis – even with treatment. The treatment of these patients should be discussed individually with the burn surgeon on duty. Patients with minor burns in a critical anatomical location in terms of function should be referred to the National Burn Centre if the injury cannot be treated locally.

The median burn size in the patient dataset was 11 % of TBSA. This is consistent with other studies of older burn patients (20–22). Four out of five actively treated patients required surgery, most often with tangential excision and split-thickness skin grafts. Most patients were operated on within 2–3 days after admission, in accordance with established international guidelines (23, 24). Around half of the operated patients required more than one operation, and for some patients the treatment was quite protracted. Poor wound healing in older burn patients may be due to an impaired immune response (9, 10).

The prognosis for older burn patients has improved in recent years (5), most likely due to early excision and skin grafting (25), developments in intensive care medicine, including nutrition and metabolism (26), and better dressing materials. The depth and extent of the burn, together with the patient's age, have previously been shown to be decisive for the prognosis (8, 27). In our data, a high percentage of TBSA with burns was associated with in-hospital death. In a recent study of 228 burn patients over the age of 65 with a median burn size of 5 %, a mortality rate of 14.9 % was found (5), while in other patient data, a higher mortality rate is reported in burn patients > 60 years of age (20, 28).

Twenty-nine out of 101 patients ≥ 75 years (29 %) died in hospital. Among the 172 patients aged 60–74 years treated at the National Burn Centre in the same time period, mortality was 12.8 %. The corresponding figure for the 45–59 age group was 7.5 % (own unpublished data). The long-term survival of patients who were discharged alive was consistent with other studies (29). One-year survival of patients discharged alive was 82 % (Figure 1). We do not have data on quality of life or functional level after discharge from hospital.

The findings regarding the relationship between comorbidity at the time of injury and survival in burn patients vary (20, 21, 30). Classifying older patients according to degree of frailty is becoming increasingly common in clinical practice and research (18). A patient who is classified as frail has a high risk of post-surgery complications, a need for a higher level of care and a greater probability of death (8, 11, 17). Assessing the patient's frailty gives a more accurate picture of their vulnerability than age and comorbidity alone, and can therefore be a useful aid in clinical decision-making. This is consistent with our data, where we found that frailty scores were associated with in-hospital deaths. It has also been shown that there is little variation and a high precision level in frailty scoring between those carrying out the assessment (31, 32). The data are therefore robust even if the scoring is carried out retrospectively (32). The level and intensity of treatment must be assessed for each individual patient.

The dataset in this study was insufficient to determine how much burn size and frailty respectively contribute to mortality. Burn size and age are the main factors when predicting mortality among burn patients (27). A research group from England recently found that a frailty score > 3 was a more sensitive predictor of one-year mortality than the modified Baux score, which is based on burn size, age and concomitant inhalation injury (33). A combination of Baux score and frailty score further improved the prediction, both with regard to in-hospital mortality and one-year mortality, compared to a modified Baux score alone (33).

Scoring frailty can therefore be an important tool in the assessment of older burn patients, also when making pivotal clinical decisions.

This retrospective cohort study has some weaknesses. The distribution of burn size among the patients was skewed: many had moderate injuries, and only 15 had 30 % of TBSA or more with burns (Table 2). The data available in the electronic patient records and the opportunity for comparison varied, particularly with regard to functional level and cognitive function/dementia, which is crucial for assessing frailty.