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 US population. This “elderly” population is the fastest growing demographic and 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 in the world is expected to exceed the number of young adults 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% to 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 physiologic and metabolic changes even more important for burn care professionals. The elderly are the age group most likely to die from severe burns. Adults older than 65 years 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 of lower physiologic reserves, higher underlying comorbidities, and limited rehabilitative capacity.

Burn injuries of the elderly occur mostly due to three major mechanisms: smoking-related accidents, mishaps while cooking, and scald burns. 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. Smoking accidents are also reflected in the rate of fire-related deaths in individuals older than 75 years old, which is four times the national average. Smoking-related burns are exacerbated by home oxygen therapy, which is common among the elderly, combined with an estimated proportion of 20% to 40% of patients who actively continue smoking despite oxygen therapy. 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). Common problems of geriatric patients that may reduce the ability to assess or control potentially dangerous behavior include diminished sensory function, cognitive defects (with or without dementia), substance abuse, and polypharmacy. ^{, ,} Most burns in older adults occur at home; therefore prevention must be focused on the home environment. ^, Sustainable efforts to educate seniors on burn prevention, the development and availability of fire-safe cigarettes, the use of timers to turn off kitchen appliances automatically, installation of specialized smoke alarms (such as low-frequency, extra-loud alarms or bed-shaking functions), as well as home safety inspections may aid in reducing the incidence of burns in the elderly. ^, Prevention should also focus on the fact that 30% of geriatric patients are the victims of self-neglect (often due to failed attempts to retain independence), and at least 10% are the victims of elder abuse.

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 30.1 .

The increased complications seen in elderly burn patients may to a certain degree result from more cautious and less aggressive treatments. This is due to existing beliefs that elderly burn patients cannot tolerate eschar excision as well as their younger counterparts, resulting in a greater delay in the excision of burn wounds. However, despite these risk factors, elderly patients have repeatedly been shown to tolerate multiple, early surgical procedures, and early wound closure corresponds to a better outcome in these patients. In general, elderly patients are treated identically to younger patients, and most differences in burn management between patient groups are related to comorbid conditions and adversities that may arise. One unique exception to this is that massive burns are more commonly managed expectantly in older adults, and palliative care may be indicated.

Geriatric burn patients are often undertreated for pain because of the misconception that less pain occurs with age and fear of deleterious side effects of aggressive pain management such as diversion, dependence, or overdose. ^, This can be detrimental because both pain and anxiety further increase the levels of endogenous catecholamines, which increase the hypermetabolic response to severe burns. Reduced clearance of many therapeutic agents occurs with aging, necessitating lower dosages ( Table 30.1 ). For this reason, pain assessment using reliable tools is essential to create an individualized treatment plan, which should also account for any comorbid conditions that may be present on admission. Untreated pain and incorrect sedation may result in posttraumatic stress disorder, major depression, and delirium. In addition, although the burn injury primarily determines the extent of the metabolic response, metabolic rates are also increased by physical activity, background pain, procedure-related pain, and anxiety. Judicious narcotic support, appropriate sedation, and supportive psychotherapy are mandatory to minimize these effects. Combination drug therapy is often required to achieve adequate analgesia. Different approaches ranging from patient-controlled analgesia to virtual reality have been found to ameliorate pain in burned patients. Intravenous drug administration is preferable during the acute phase. A proactive geriatrics consultation team may also be beneficial in managing pain. Use of only comfort care measures needs to be considered for elderly patients with burns likely to be fatal.

Aging produces many changes in the cardiovascular system that make hemodynamic stability more difficult to achieve and increase adverse outcomes. Coronary artery disease is prevalent, being estimated to exceed 80% in patients older than 80 years of age. Elderly patients are at higher risk for congestive heart failure, and special considerations should be taken during acute and long-term treatments. The revised cardiac risk index stratifies patients into risk groups and helps identify those likely to need additional cardiac evaluation. Patients with minor perfusion abnormalities undergoing low-risk surgery may not require catheterization but should be considered for prophylactic β-blockers and aspirin before operation. High-risk subgroups of patients identified based on clinical risk factors and positive noninvasive tests should undergo cardiac catheterization. Patients with significant cardiac lesions should have definitive coronary revascularization via angioplasty before large TBSA burns are excised. The potential benefits of using β-adrenergic blocking agents during the perioperative period have been studied ^, because perioperative ischemic events are related to an exaggerated postoperative sympathetic response that leads to an increased heart rate. ^, β-Blockade has an added advantage in burn patients : severe thermal injury induces hypermetabolism that persists for up to 9 to 12 months, and the resting metabolic rate in burn patients doubles for those injuries covering greater than 40% TBSA. Catecholamines are key in the initiation of various cascades that stimulate postburn hypermetabolism. Preventing initiation of these cascades by blocking the action of catecholamines at the receptor level using β-blockers such as propranolol attenuates this response and reduces supraphysiologic thermogenesis, tachycardia, cardiac work, and resting energy expenditure.

The drawback of β-blockade in older adults is that the aging cardiovascular system is less responsive to β-receptor stimulation. This decrease, together with anesthetic agents, may lead to deleterious intraoperative hypotension in the presence of prophylactic β-blockade. Further investigations are necessary to determine the most appropriate therapeutic regimen for reducing perioperative ischemia, cardiac morbidity, and postburn hypermetabolic responses in older adults.

Pulmonary complications are more strongly linked to coexisting comorbidities than to chronologic age. Because of the prevalence of chronic obstructive pulmonary disease and asthma in older adults, physicians should be alert for these conditions during perioperative evaluation. With the appropriate diagnosis, aggressive pulmonary rehabilitation including exercise training, patient education, smoking cessation, and medication optimization is effective in elderly patients. All of these aspects must be integrated into long-term patient management. Aggressive use of antibiotics, judicious use of bronchodilators, adequate hydration, postural drainage, and chest physiotherapy reduce the incidence of pneumonia, atelectasis, and other pulmonary complications.

Burn rehabilitation is a long multidisciplinary process that aims to preserve patients’ functional ability and restore independence. Physical and occupational therapy should begin immediately after injury. Important components of rehabilitation include wound healing, scar prevention and correction, splinting, casting, traction, pressure therapy, pharmacologic therapy, exercise, and psychological support. Older adults should be aggressively managed during rehabilitation to avoid any further loss of function or strength, which are difficult to recover. Older patients are capable of recovering muscle strength with resistance exercise and should not be managed conservatively. As with children, providing support and guidance for caretakers is essential because these individuals will be responsible for the patient’s well-being upon discharge. ^,

Identifying physical abuse by burning in older adults is difficult because no pathognomonic signs exist. Although such abuse is relatively rare, professionals consistently underestimate the prevalence of elder abuse. The growth in the elderly population makes it necessary to raise awareness among health professionals and reevaluate the clinical approach and assessment for burn injuries inflicted intentionally or negligently. Older adults often live alone, interacting predominantly with the caregivers who enact their abuse. These patients may keep their abuse a secret because of shame, guilt, or fear of reprisals. ^, Most forms of intentionally inflicted burns have a higher associated morbidity and mortality than equivalent accidental burns, in part because of comorbidity from other physical abuse, substance abuse, or psychological problems that contributed to or resulted from the inflicted burn. Elder mistreatment can be associated with confidentiality difficulties because they may not want abuse reported. The priority of the examining physician is to treat life-threatening conditions. They should then promptly record symptoms and signs of abuse or neglect (including photographs). Deliberately inflicted burn injuries are best managed by a multidisciplinary team of healthcare, social service, and legal professionals.

Despite the remarkable reduction in mortality in burned children over recent decades, we have not yet achieved the same results in elderly patients. This age group still constitutes a major challenge. Surgical decision-making in these patients must take into account physiologic age, preburn functional status, degree of impairment from comorbid conditions, and clear treatment goals. No patient should be denied an operation based on age alone because age-related declines in organ function are predictable for the population but not necessarily for the individual. More so, the burn surgeon’s general mindset should be to treat geriatric patients as aggressively as younger patients. Currently, no “score” can improve decisions based on a thorough evaluation and discussion with the patient and family. Favorable outcomes in elderly burn patients should pertain more to relieving suffering and maintaining independence and quality of life rather than expanding lifespan. Clear, repeated communication between the burn team and patients or their surrogates is critical for guiding therapy and achieving acceptable outcomes.