Editorials

Preventing Burns in Older Patients



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Am Fam Physician. 2006 Nov 15;74(10):1688-1693.

For older adults, burns and fire-related injuries are the second leading cause of death from accidental injury in the home.1 Cigarette smoking and alcohol use contribute to many of these injuries. However, the role of dementia as a risk factor for burns and fires is not clear. Dementia is extremely prevalent in community-dwelling elderly persons and often is unrecognized by primary care physicians.2

Accidents while cooking are a leading cause of major burns in older adults.3 However, primary care physicians often fail to discuss the potential for cooking-related injury with older patients. Few data are available to guide physicians in evaluating a patient's risk. Warning signs of unsafe behavior may include a history of minor burns, burned food and utensils, or failing to turn off the stove. Physicians should ask patients and caregivers about these signs. Timers may be a useful adjunct for patients with mild cognitive impairment. If necessary, caregivers may need to remove the knobs from stoves to prevent patients from cooking while unsupervised. Unless they are directly supervised, patients with significant cognitive deficits must discontinue cooking.

Fatal tap water burns occur disproportionately in older persons and are associated with falls, syncope, and inadequate supervision of patients with dementia.4 Older adults and caregivers should be counseled that the recommended maximal temperature for residential hot water heaters is 120°F (48.9°C). Researchers have found that adaptive safety equipment (e.g., grab bars, bath seats) often is not present in the bathrooms of older persons who are at increased risk of falls.5 As a result, physicians should review the need for adequate supervision and bathroom safety equipment in the homes of patients with dementia and disabilities who are at high risk of household accidents.

Primary care physicians may increase a patient's risk of sustaining a burn by prescribing certain medications and medical equipment. Benzodiazepine use, for example, has been associated with major burns.6 Psychotropic drug use in older adults should be reviewed carefully, and attempts should be made to taper or eliminate unnecessary medications. Heating pads are another common cause of minor burns and may lead to major burns in older adults with sensory or cognitive deficits.7 As a result, recommendations for the use of heating pads must be weighed carefully against the potential for injury. Burns and fires from home oxygen use occur primarily in patients who continue to smoke. Home oxygen should be prescribed only when a plan exists to train and educate caregivers about the danger of smoking while using oxygen, to notify the physician if a patient resumes smoking, and to check for a functional smoke detector in the patient's home.8

Smoke detectors clearly reduce mortality rates in residential fires, even in the homes of older persons with physical or cognitive disabilities.9 Yet, up to one quarter of households in the United States are estimated to not have functional smoke detectors. Special smoke detectors are available for persons who are deaf or have hearing difficulties. Experts recommend counseling older adults on measures to reduce home accidents and fire risk as part of routine office-based care.

Of the approximately 1.1 million annual burn injuries in the United States that require medical attention, only 5 percent are estimated to require hospital admission; the remaining cases are managed in the community.10 Minor burns may help physicians identify patients who are at increased risk of home accidents and potentially life-threatening burns. Physicians caring for an older patient with a minor burn should consider the possibility of dementia as a contributing factor in the injury. The patient's history also should be reviewed for the use of cigarettes, alcohol, and benzodiazepines and other psychotropic medications. High-risk activities such as smoking, cooking, and bathing should be targeted in patients with dementia. If appropriate, physicians should refer older patients who present with a minor burn to a home care agency. In this setting, a home safety evaluation may detect potential risks for recurrent burns.

Address correspondence to Amy R. Ehrlich, M.D., at aehrlich@montefiore.org. Reprints are not available from the author.

REFERENCES

1. Runyan CW, Casteel C, Perkis D, Black C, Marshall SW, Johnson RM, et al. Unintentional injuries in the home in the United States. Part I: mortality. Am J Prev Med. 2005;28:73–9.

2. Brigham PA, McLoughlin E. Burn incidence and medical care use in the United States: estimates, trends, and data sources. J Burn Care Rehabil. 1996;17:95–107.

3. Callahan CM, Hendrie HC, Tierney WM. Documentation and evaluation of cognitive impairment in elderly primary care patients. Ann Intern Med. 1995;122:422–9.

4. Turner DG, Leman CJ, Jordan MH. Cooking-related burn injuries in the elderly preventing the “granny gown” burn. J Burn Care Rehabil. 1989;10:356–9.

5. Walker AR. Fatal tapwater scald burns in the USA, 1979–86. Burns. 1990;16:49–52.

6. Naik AD, Gill TM. Underutilization of environmental adaptations for bathing in community-living older persons. J Am Geriatr Soc. 2005;53:1497–503.

7. McGill V, Kowal-Vern A, Gamelli RL. Outcome for older burn patients. Arch Surg. 2000;135:320–5.

8. Bill TJ, Edlich RF, Himel HN. Electric heating pad burns. J Emerg Med. 1994;12:819–24.

9. Joint Commission on Accreditation of Healthcare Organizations. Sentinel event alert. Lessons learned: fires in the home care setting, 2001. Accessed August 25, 2006, at: http://www.jointcommission.org/sentinelevents/sentineleventalert/sea_17.htm.

10. Marshall SW, Runyan CW, Bangdiwala SI, Linzer Ma, Sacks JJ, Butts JD. Fatal residential fires: who dies and who survivess. JAMA. 1998;279:1633–7.


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