Overview of burn injury in older patients

INTRODUCTION — Older adults are more prone to burn injury and are also more likely to develop complications after injury. Although aging is a continuous process influenced by the individual's lifestyle and comorbidities, the age that defines the older adult is variably defined (eg, ≥45 years in some studies, ≥80 years in others). Treatment outcomes are overall worse for older compared with younger adults. As the proportion of older adults increases, the medical, economic, and social burdens of burn injury will likely increase as well [1,2].

The incidence, physiologic factors, and challenges associated with managing burn injuries in older patients are reviewed here. General management of burn injuries for the broad adult population is reviewed separately and provided in the linked topics below. (See "Overview of the management of the severely burned patient".)

EPIDEMIOLOGY AND RISK FACTORS — The incidence of burn injuries in older adults is increasing as the age of the population increases in many countries throughout the world. Older adults represent a disproportionately higher percentage of hospitalizations due to burns compared with the general population [3,4]. In the United States, burns in older patients comprise up to 20 percent of burn injuries [1], whereas in a prospective study from Egypt, burns in older adults represented 2.3 percent of all treated burns but 7.1 percent of all hospital admissions, in an area where older adults comprised only 5.8 percent of the total population [3]. Burns among older adults are less common in some other countries, accounting for less than 5 percent of burns in Southeastern Asian and Middle Eastern countries [1].

An 11-year review of data from the Coroners Departments in Greater Manchester in the United Kingdom from 2000 through 2010 showed that although the risk of death from burns has declined over time, the largest proportion of burn deaths was occurring in adults aged >75 years [5].

Risk factors — Many factors predispose the older adult to burn injury. Some of these include smoking, limited mobility and slower reaction time, sensory impairment, decreased coordination, side effects of medication, and cognitive decline [6]. General risk factors for burn injury are reviewed separately. (See "Epidemiology, risk factors, and prevention of burn injuries".)

Most burns in older adults occur in the home. Household fires and smoking-related injuries account for approximately 65 percent of older patients requiring admission to US burn centers [7,8]. Other causes of burn injuries in older adults include scalds (estimated at 15 to 30 percent) and contact injuries (5 percent) [7,8]. In an Egyptian study, most burns among older patients occurred at home during the day when the individual was left alone [3].

Risk-taking behaviors (smoking, alcohol impairment) also predispose the older adult to burn injury. Males comprise the majority of injuries, but the proportion of burn-injured females increases with age.

Lower socioeconomic status increases the risk of house fires and the likelihood of sustaining burns from a house fire. Certain types of homes with substandard safety features (eg, mobile homes, rental properties) predispose the older adult to burn injury. Individuals living in homes without a functioning smoke detector are more than eight times as likely to have an injury related to a house fire. Even when smoke detectors are installed and functioning properly, the older adult with a hearing difficulty is less likely to respond to the alarm from smoke detectors [9]. Living in a rental property or mobile home increases the risk of burns twofold, whereas smoking and alcohol impairment each increase the risk at least fourfold [10].

In rural communities, burning brush, trash, and other debris often injures older men, particularly when fuel is used as an accelerant [11]. A retrospective review of 759 burn patients admitted to a US burn unit between 1990 and 1994 found that the most frequent cause of death for older adult females with burns was cooking-related injuries resulting in clothing ignition [12]. Cooking on a gas stove, isolation, slowed behavioral responses, mental and physical disabilities, and inability to access assistance were contributing factors.

Hot water scalds continue to occur in spite of existing educational programs and legislative interventions to reduce home water temperatures [13]. Decreased mobility, impaired sensorium, diabetic neuropathy, and not following recommendations are common factors that predispose older adults to tap water scalds. Environmental factors include lack of access to water temperature controls in some buildings or living in buildings exempt from current law [14]. According to a British review of burns occurring in residential care facilities, inadequate staff supervision accounts for the majority of hot water scalds as well as contact with radiators when residents with dementia and impaired mobility were left unsupervised [15].

Older adults, particularly those with diminished physical and cognitive abilities, are also at risk for physical abuse and neglect. Nonaccidental burn injuries are frequently underreported, which adds to the challenges in the recognition and management of these injuries [15].

PREVENTIVE STRATEGIES — Among older individuals, preventive strategies most likely to reduce the risk of burn injury include strong smoke detector legislation with proper enforcement, home inspections paired with an educational intervention, smoke detector giveaway campaigns, and community education campaigns [16-21]. Any prevention program, however, must be sustained by repeat engagement with older adults in their communities. Otherwise, compliance with prevention measures will decrease over time. As an example, batteries may be removed after false alarms, and expired batteries may not be replaced. Preventive strategies require a multipronged approach.

PATHOPHYSIOLOGY OF BURN INJURY — Burn wounds produce severe physiologic stress, the magnitude of which increases proportionally with burn size. The response to this physiologic stress differs for older compared with younger patients due to aging-related alterations and reductions in physiologic reserve.

The hypermetabolic response includes (see "Hypermetabolic response to moderate-to-severe burn injury and management"):

●Altered hemodynamics – An initially low cardiac index and profound vasoconstriction, followed by a persistent hyperdynamic state with tachycardia and increased resting energy expenditure.

●Altered glucose metabolism – Enhanced gluconeogenesis, hepatic glucose release, and glycogenolysis lead to hyperglycemia.

●Altered protein and lipid metabolism – Reduced ability to use fats for energy leads to lean muscle breakdown. Persistent protein catabolism causes weakness and impairs wound healing.

Aging-related changes — Age-related physiologic changes and comorbidities contribute to the severity of injury and predict worse hospitalization outcomes in older patients [22]. The age cutoff that defines an older adult has been anywhere from ≥45 to ≥80 years in the prior literature, although "normal" aging is a continuous process influenced by the individual's lifestyle and comorbidities [23,24]. (See "Normal aging".)

Cardiovascular system — With aging, maximum oxygen consumption decreases approximately 1 percent per year, with a reduction in maximal cardiac output accounting for most of the changes over time. By contrast, systemic vascular resistance rises 1 percent per year [25]. In addition, the left atrium enlarges and the left ventricle stiffens with aging [26]. Maximal heart rate and responses to adrenergic stimulation are also reduced with age. Thus, as a result, the early hypermetabolic response and resting energy expenditures are attenuated in older adults compared with younger patients with burns; however, the hypermetabolic response increases over two weeks and is then greater relative to younger adults [27,28]. Another issue is that increased cardiovascular system stiffness causes the resting systolic pressure to rise, increasing the susceptibility of the aging cardiovascular system to hypovolemia, with a greater reduction in stroke volume and systolic pressures for the same degree of volume loss.

Renal system — Normal aging is associated with diffuse sclerosis of glomeruli such that 30 percent of glomeruli are destroyed by age 75 [29]. The remaining glomeruli have impaired filtering ability. Morphological changes are often accelerated in the setting of diabetes and hypertension. The inability to maximally dilute urine and excrete a water load compromises volume regulation under conditions of stress. Decreased glomerular filtration rate (GFR) renders aging kidneys susceptible to secondary physiologic insults, such as sepsis, acute kidney injury, and multiple organ dysfunction that may develop during critical illness.

Respiratory system — Respiratory performance decreases with age because of reduced chest wall compliance, decreased diaphragm strength, and alveolar airspace enlargement. Relative to younger patients, clinical observations support that older compared with younger adults are more prone to respiratory fatigue, and to aspiration. The hyperdynamic response associated with burn injury leads to muscle breakdown, which may further compromise respiratory function. Older patients also have more fatty infiltration in the muscle leading to increased catabolism.

Gastrointestinal system — The aging liver has a reduced ability to clear drugs and is less resilient to physiologic insults associated with injury, such as hypoperfusion. As an example, the liver in aging mice is less able to generate the cytoprotective heat shock protein 70 (Hsp70) in response to ischemia/reperfusion injury [30]. Burn injury also promotes a persistent deficiency in insulin synthesis from pancreatic beta cells and insulin resistance from the aging liver. Clinically, the percentage of older patients treated with exogenous insulin is higher than in younger adults, with significantly higher glucose variability throughout the day [27]. Aging of the gastrointestinal system in itself does not cause malnourishment. However, a 2005 study of hospitalized burn patients >65 years old described a 61 percent incidence of preexisting protein-energy malnutrition [31]. These data are congruent with a 30 to 60 percent incidence of malnutrition reported in older patients acutely hospitalized for other conditions [32,33].

Chronic malnutrition may also be related to a high incidence of dysphagia in older adults [34]. Swallowing dysfunction in older patients is related to relative weakness in muscles of deglutition, increased transit time through the pharynx, and a higher risk of aspiration. Patients with a prior history of stroke or neurodegenerative disease are at highest risk. Swallow dysfunction is often underdiagnosed because many older patients do not report symptoms and adapt by changes in diet and meal sizes [35,36]. The high prevalence of chronic malnutrition in older adults is closely linked to the development of sarcopenia and negatively affects all aspects of wound healing. Clinically, malnourished older burn patients have marked higher lengths of hospitalization and twice the hospital mortality rate compared with well-nourished patients [31].

Skin — As individuals age, there is a loss of function and structural stability in skin. Aging of the skin impairs neurosensory perception, increases permeability, and reduces the response to injury and the capacity for repair [37,38].

The dermal-epidermal junction (rete ridges) flattens, making the epidermis more prone to shearing [37]. This has important implications for the care of older burn patients as routine measures such as intravenous (IV) catheter cannulation, mobilizing the patient, and skin harvesting for donor sites can cause skin shearing and therefore increase the total wound size burden on the older patient.

Aging also alters all phases of wound healing, from hemostasis and inflammation to proliferation and resolution [39]. The rate of epidermal turnover is reduced by 50 percent after age 65, with fewer epidermal-lined skin appendages (hair follicles, oil and other glands) to permit reepithelialization via keratinocyte proliferation [40]. Clinically, burn providers often observe that shallow-appearing burns in older adults have markedly delayed reepithelialization (well over three weeks) or, worse, that initial shallow-appearing burns often become indistinguishable from full-thickness burns on reexamination, a process called "wound conversion." Skin grafting in older adults is associated with higher rates of graft complications and loss. Delayed re-epithelialization of donor sites can be a major barrier to recovery in older adults after split-thickness skin harvesting and warrants a search for new strategies to achieve faster donor site healing older patients [41-43].

Immune system — Aging alters multiple functions of innate immune cells. Aging also affects cell-mediated immunity with atrophy of the thymus, reduced naïve T-cells, and decreased T-cell memory. At baseline, healthy older adults already exhibit a chronic inflammatory state, characterized by higher circulating levels of proinflammatory mediators (so-called "inflamm-aging") [44]. Compared with younger adults, older patients have a reduced inflammatory response to major burn injury, with limited rise in acute phase reactants and with down-regulation of antigen-processing and cell signaling pathways [28,45]. Adipocyte transformation from white to beige in response to the catecholamine surge after injury is important for heat production and increased energy expenditure. This process, called "white adipocyte browning," is attenuated in older patients with major burns [46].

Host immune changes may partially account for a higher susceptibility to infections in older adult patients [47,48]. The combination of burn and sepsis is a strong risk factor for multiple organ dysfunction syndrome and death [49]. In a burn registry review that included 187 adults >55 years, burn wound infection developed in 44.3 percent of patients [50].

Effect of comorbidities and frailty — Preinjury comorbidities are very common in older adults with burn injury (as high as 85 percent) and frequently complicate the care of older burn patients [51]. Burn injury may also uncover comorbidities that were previously unknown.

●Smoking and chronic obstructive lung disease strongly predict the development of pulmonary complications [52]. Patients on oxygen therapy who continue to smoke may be difficult to wean from mechanical ventilation following inhalation injury.

●Cardiac dysfunction may alter the timing of surgical procedures and can delay liberation from mechanical ventilation. Additional tests and invasive monitoring may be necessary to optimize patients with cardiac dysfunction.

The frail older patient has a diminished ability to recover from mechanical ventilation, multiple operative interventions, and sometimes temporary immobility imposed by burn injury and critical illness. Frailty is defined by declining physical function and vulnerability to additional physical insults. This common syndrome in older patients has some overlap with comorbidities and disability. (See "Frailty".)

Frailty can cover many domains, from physical to cognitive and social. Frailty can be assessed mainly by a patient’s level of activity and nutrition status. Physical frailty is associated with a progressive loss of lean body mass (weight loss >5 percent in a year), weakened muscle strength, reduced physical function (eg, decrease in walking speed), or the appearance of unusual fatigue [53,54]. Debate continues on the best method to assess frailty in the injured older adult, from relying on specific frailty scales, performing functional evaluations, or using imaging as a surrogate [55,56].

Frailty itself is an important risk factor for poor hospitalization outcomes after burns [57-59]. Postburn hyperdynamic and hypermetabolic responses are relatively blunted in frail older adults, but these patients still suffer from persistent catabolism and loss of lean body mass [60]. Altogether, these factors constitute an enormous barrier to physical recovery in older patients.

Burn size and depth — Although burns in older adults affect less of their total body surface area (TBSA), older adults typically sustain deeper burns. A review of 201 patients compared burn size and depth in patients older and younger than 65 years [61]. Injury TBSA was lower for older patients (13 versus 22.5 percent), but the proportion of deep burns/total area injured was higher for the older patients (41 versus 23.3 percent).

MANAGEMENT — The general management of the older burn patient follows the same strategies as with younger patients; however, their physiologic differences introduce management challenges. These are reviewed in the following sections. (See "Overview of the management of the severely burned patient".)

Delayed wound healing and complications often prolong the hospitalization course of the older burn patient. The commonly cited one day of hospitalization for every percentage surface area burned does not apply to older adults. In the United States, the average length of stay indexed to total body surface area (TBSA) burn is approximately 2.8 days for patients aged ≥65 years and 3.3 days in those ≥75 years [8].

Comanagement with geriatric specialists is an attractive care model with proven outcome benefits in other types of geriatric trauma but remains to be specifically tested in older burn patients [62,63]. The following sections highlight distinct care challenges for older patients through each phase of care (resuscitation, wound coverage, and rehabilitation).

Fluid resuscitation — Age alone should not be a criterion to forego acute resuscitation. Each patient should be individually assessed for the potential for survival and rehabilitation. In the absence of specific data to guide geriatric resuscitations, we initiate fluid resuscitation by weight and burn size according to standard estimates for all adults, with subsequent adjustments based on individual patient response. Some have attempted to provide a formula with a compensating factor for advanced age [64]. (See "Emergency care of moderate and severe thermal burns in adults", section on 'Fluid resuscitation' and "Overview of the management of the severely burned patient", section on 'Initial stabilization' and 'End-of-life decisions' below.)

Because older patients are less able to tolerate over- or under-resuscitation given their limited cardiopulmonary reserve, providers often wish to limit fluid infusion, but there is little evidence so far to support this practice. With carefully titrated fluid resuscitation, central pressures do not typically increase. Lung edema appears to be more closely associated with direct lung injury from inhalation or secondary lung injury from shock and sepsis, rather than from large-volume resuscitation [65,66]. On the other hand, acute kidney injury occurs more commonly in older adults during the resuscitation phase, although it remains unclear whether this is due to under-resuscitation or from other causes [67].

Early burn wound excision and grafting — For older patients with burns ≥20 percent TBSA, we perform surgical excision following completion of fluid resuscitation, and before seven days. Our rationale is that removal of the large burn eschar is essential for survival; older patients do not tolerate burn wound sepsis. (See "Overview of surgical procedures used in the management of burn injuries", section on 'Burn scar revision and timing'.)

Early excision remains a prudent approach for full-thickness burns ≥20 percent TBSA given the eschar burden. However, early excision (within seven days of injury) in older adults remains controversial [68,69]. Mortality, infection rates, and length of stay are not uniformly improved for early burn wound excision [7,51,70]. The rates of burn wound infection and sepsis are not appreciably higher for older compared with younger adults, except perhaps at the extremes of age. However, many burn surgeons believe the incidence in older adults is underreported and may be as high as 80 percent, which supports our preference for burn excision as soon as tolerable by the patient. (See "Burn wound infection and sepsis".)

Preoperative medical optimization is advisable with smaller-size burns when the risks of the surgical procedure outweigh the benefits of early wound closure. In some cases, delaying surgical burn excision is wise.

Delayed wound healing and poor graft take are important problems in older burn patients. Interstices in expanded mesh grafts are slow to fill, and both grafted beds and donor sites are more prone to infection. Despite harvesting thin grafts, it is often not possible to safely reharvest from the same donor sites within several weeks. Delayed reepithelialization means that the older patient has to be hospitalized longer with open wounds. The patient is confronted with a more difficult rehabilitation process with sometimes prolonged, painful dressing changes.

Pain management — Pharmacologic pain treatment should be initiated at smaller doses in older burn patients compared with younger adults and carefully titrated for comfort. (See "Management of burn wound pain and itching" and "Paradigm-based treatment approaches for management of burn pain" and "Pain control in the critically ill adult patient".)

Pain assessment is challenging in this population. Although older patients report decreased acute pain perception in some circumstances (such as acute myocardial infarction), they are at increased risk of neuropathic pain with tissue injury, temporal summation, and persistent hyperalgesia [71]. Older patients are more likely to become disabled by pain compared with younger adults [72]. The numeric rating scale (NRS), verbal description scale (VDS), or McGill Pain Questionnaire are recommended over the standard visual analog scale (VAS) in older patients [73]. Observational scales become necessary when cognitive impairment or mechanical ventilation precludes self-reporting. Numerous observational measurements have been specifically developed for older patients [74].

Providers should be cautious when dosing pharmacologic agents to relieve pain in older adults. The initial opioid analgesic dose for acute pain should be 25 to 50 percent of that in younger adults and carefully titrated upward to achieve comfort. Titration is paramount as undertreated pain is a risk factor for acute delirium and postoperative cognitive dysfunction (POCD) [75]. Common side effects of nonsteroidal anti-inflammatory agents are gastrointestinal bleeding and renal toxicity. Barbiturates, benzodiazepines, and tricyclic antidepressants are other classes of agents that require caution in older patients because of decreased clearance and side effects. Pharmacists and geriatricians' expertise can contribute greatly to the multidisciplinary team's ability to titrate medications and minimize polypharmacy.

Acute delirium disproportionately affects older hospitalized patients because of pain, infection, inadequate sedation, and intrinsic host factors such as dementia [6,76-78]. In a retrospective review of patients 70 years and older hospitalized with burn injuries, risk factors associated with delirium included advanced age, increased American Society for Anesthesiologists score, impaired physical abilities, and the use of anticholinergic drugs during admission [79]. Patients with delirium had a poorer outcome, with prolonged hospital stay and increased mortality 6 and 12 months after discharge. Although it is easy to recognize hyperactive delirium in agitated patients who pose a danger to themselves and their environment, hypoactive delirium is much more common and underrecognized. In this instance, the patient appears apathetic and withdrawn and has decreased responsiveness. The benzodiazepine lorazepam is an independent risk factor for delirium, whereas dexmedetomidine decreases the incidence of delirium [80]. Given the limitations of traditional pharmacologic treatments, it is clear that nonpharmacologic approaches are needed to improve the care of older burn patients.

Nutritional and metabolic support — Early provision of nutritional support, maintenance of warm ambient temperatures, and control of infection are important strategies to mitigate the hypermetabolic response to burn injury that results in a catabolic state [81]. (See "Hypermetabolic response to moderate-to-severe burn injury and management", section on 'Attenuation of the hypermetabolic response'.)

Pharmacologic agents to modulate hypermetabolism in older adults may achieve a similar benefit to those demonstrated in children and younger adults with severe burns. Oxandrolone, a testosterone analog with weak virilizing potential, had shown promise in treating hypermetabolism in prior trials. However, in 2023 the US Food and Drug Administration withdrew approval out of concern for significant side effects [82]. (See "Hypermetabolic response to moderate-to-severe burn injury and management", section on 'Attenuation of the hypermetabolic response'.)

The nonselective beta blocker propranolol reduces tachycardia, energy expenditure, and substrate cycling and prevents fatty acid infiltration of the liver in severely burned children, but its application has not yet been rigorously evaluated in older adults with burns. Beta-adrenergic blockade is particularly appealing since aged patients do not tolerate tachycardia well. However, the benefits of this strategy must be weighed against the associated risks (eg, bradycardia, hypotension) [83]. (See "Hypermetabolic response to moderate-to-severe burn injury and management", section on 'Propranolol'.)

Aging is associated with alterations in energy metabolism, which dramatically changes the size and distribution of fat deposits and predisposes older adults to metabolic disorders and, in particular, insulin resistance [54]. As a result, the percentage of older patients with burns treated with exogenous insulin is higher than in younger adults, with significantly higher glucose variability throughout the day [27]. (See "Hypermetabolic response to moderate-to-severe burn injury and management", section on 'Glycemic control'.)

Rehabilitation — For geriatric burn patients to regain eventual independence, aggressive treatment is needed to prevent burn-specific complications of hypertrophic scarring and contractures, heterotopic ossification, neuropathy, and psychological sequelae [4,84].

The severity of scarring is greater with younger age, although older adults can still develop significant hypertrophic scars [85]. A study from Italy, using a Bayesian network model, estimated that patients >65 years old have a 54 percent probability of developing a pathological scar, compared with 70 percent in patients <15 years old [86]. The pros and cons of every treatment must be weighed. As an example, the duration of splinting and immobilization to avoid graft shear should be minimized to prevent disuse atrophy and pressure ulceration in older patients.

Early mobilization and exercise regimens benefit older patients in numerous ways, including improved general health, faster hospitalization recovery, and reduced repeat injuries [54,87,88]. Exercise should be a core component of a comprehensive rehabilitation plan but thus far remains to be validated in older adults with burns; however, the general critical care literature regarding mobilization is broadly applicable to older burn patients. This approach begins during acute care and is continued throughout the rehabilitation process, whether in-hospital, at a rehabilitation facility, or at home. Any barrier to early mobilization (ie, oversedation and bed rest orders) must be removed as early as possible. Minimizing sedation and providing therapy/guided ambulation are particularly important for older patients and should become part of routine care even while on mechanical ventilation [89].

Whether the patient undergoes treatment at an inpatient rehabilitation facility (IRF) also impacts outcomes in older burn patients. In the United States, the rate of adult burn patients referred to IRFs varies by as much as fivefold [90]. Collaboration between the burn and inpatient rehabilitation teams is essential to improve functional outcomes as it increases the likelihood that patients qualify for inpatient rehabilitation. Altogether, an aggressive strategy that involves physiatrists early in the care of major burns is associated with a higher rate of return to independent living [91].

End-of-life decisions — Age alone should not be a criterion to forego acute resuscitation. Each case should be individually assessed for the potential for survival and rehabilitation. (See "Overview of the management of the severely burned patient", section on 'Palliative care'.)

Providers often advocate withholding life-sustaining therapies when the extent of burn injury precludes survival or when the patient's deterioration indicates a lack of response to medical interventions [92-94]. Defining futility for the older burn patient is based on the providers' own experiences, the available literature, and taking into account advances that may push the hope for survival. Independence, function, and quality of life for older adults after major burns are far more important factors to guide aggressiveness of care. The process and quality of the communication between providers, patients, and family members or other caretakers can reduce anxiety and distress [95,96]. Severely injured patients who remain alert can potentially participate in shared decision making. For patients who are not able to participate, providers must rely on the substitute judgment of designated surrogates. For patients who lack a surrogate, physicians must provide substitute judgment based on their best estimate of the likelihood for survival and rehabilitation in each individual circumstance.

MORBIDITY AND MORTALITY — Along with percentage total body surface area (TBSA) and concomitant inhalation injury, older age has consistently been associated with increased morbidity and mortality following burn injury.

Burn-related injury is the fourth leading cause of unintentional injury mortality among people aged 65 years or older [97]. Older adults have a disparately increased morbidity and mortality following burn injury compared with children and young adults [8,27,98,99]. Although several centers have reported improved outcomes over time, improvements in survival lagged far behind younger cohorts [8,100,101].

●The National Burn Repository reports that in the United States, a lethal burn area associated with 50 percent mortality (LA50) in the 60- to 69-year-old age group is less than 50 percent TBSA [102].

●Even in high-volume burn centers, LA50 for patients ≥60 years old remains approximately 35 percent TBSA and has not substantially improved over the last two to three decades [103]. By contrast, a young healthy adult with a 75 percent TBSA burn has a better than 50 percent chance of survival.

●In a review of 301 patients, older adults had significantly higher mortality than patients under 65 (48 versus 24 percent; odds ratio [OR] 2.9, CI 95% 1.6-5.2) [61]. When adjusted for TBSA and deep TBSA/TBSA proportion, the risk of death increased 12-fold.

Older patients are at high risk for multiple in-hospital complications. Pneumonia is the most common complication in older hospitalized burn patients, affecting 8.6 percent of older adults hospitalized in United States burn centers. This may be due to a maladaptive immune response to infectious challenge and the resulting sequelae (sepsis, multiorgan dysfunction) [104]. However, the risk of pneumonia, is more closely associated with inhalation injury, the extent of skin injury (TBSA), and the number of comorbidities, rather than age [52]. (See "Inhalation injury from heat, smoke, or chemical irritants".)

Older adults who survive their injuries are at greater risk for long-term disability and loss of independence [105]. Older burn patients are also at high risk for repeat hospitalization and late deaths, particularly if they are discharged to skilled nursing facilities [106,107]. Whereas discharge to home and return to independent living are clearly desirable, these goals are often not achieved in older burn patients. Up to 50 percent of patients >75 years old are discharged to skilled nursing facilities (SNFs) after major burns, which portends a higher likelihood of death in the months following hospitalization [91,108]. Risk factors related to SNF discharge dispositions are often related to age and preexisting conditions that lead to frailty [57]. Older age is also associated with reduced long-term survival for up to two years after the initial burn injury. Additional research is necessary to clarify functional and quality-of-life outcomes in older burn survivors [109].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)

SUMMARY AND RECOMMENDATIONS

●Burns in older adults – Factors that predispose the older adult to burn injury include smoking, physical disability, sensory impairment, and dementia. Household fires and smoking-related injuries account for approximately 65 percent of burn injuries in older patients. Hot water scalds continue to occur in spite of efforts for prevention. (See 'Epidemiology and risk factors' above.)

●Burn pathophysiology – Burn wounds produce severe physiologic stress, the hypermetabolic response to burn injury, the magnitude of which increases proportionally with burn size. Age-related changes contribute to decreased physiologic reserve in many organ systems and to alterations in wound healing. (See 'Pathophysiology of burn injury' above.)

●Burn management – The general management of the older burn patient follows the same strategies as with younger patients; however, the physiologic differences introduce challenges for the management of the older patient. (See 'Management' above.)

•Fluid resuscitation – Acute fluid resuscitation in older patients should be initiated using the same guidelines as for younger patients. Age alone should not be a criterion to forego acute resuscitation. Each case should be individually assessed for the potential for survival and rehabilitation. (See 'Fluid resuscitation' above.)

•Burn wound excision and grafting – For older patients with burns ≥20 percent total body surface area (TBSA), we perform burn excision following completion of fluid resuscitation, and before seven days, though early burn wound excision remains controversial in this population. (See 'Early burn wound excision and grafting' above.)

•Burn pain – Pain may be more difficult to assess in older adult patients. Pharmacologic pain medications need to be initiated at smaller doses and carefully titrated for comfort. (See 'Pain management' above.)

•Hypermetabolism – The effects of beta blockade for attenuating hypermetabolism have not been rigorously evaluated in older adults with burns, and their use must be individualized, weighing the potential benefits against the risks (eg, bradycardia, hypotension). (See "Hypermetabolic response to moderate-to-severe burn injury and management", section on 'Propranolol'.)

●Outcomes in older burn patients – Burn treatment outcomes are worse for older compared with younger adults, with older adults more likely to develop complications after burn injury, which include pneumonia, acute delirium, and death. Older burn patients are also at high risk for repeat hospitalization and late deaths, particularly if they require posthospitalization nursing care. (See 'Morbidity and mortality' above.)